REPUBLIC OF THE PHILIPPINES )

CITY of ________ ) s.s.

PROVINCE OF ________________)

AFFIDAVIT OF LOSS - TAX DECLARATION

I, __________, of legal age, Filipino, single and with residence at

_______, __________, after having been duly sworn on oath in accordance with
law, freely and voluntarily, without undue pressure from anyone or fear of
intimidation, hereby depose and say that:

1. That I am the incumbent Provincial Governor of the

_____________;

2. That the Province of ____________is the registered owner of a

parcel of land which is situated in Brgy._______, ___________,
having an area of _____ square meters;

3. Unfortunately, the said Transfer Certificate of Title No.______

was misplaced and cannot be located from the usual place where
the same is kept despite diligent efforts of finding the same;

4. That I now consider the said TCT No. _______ lost for all
intents and purposes;

5. That I am executing this affidavit to attest to all the foregoing

statements in good faith and to request the Honorable Registry of
Deeds of __________for the issuance of a new copy of TCT
No.______.

IN TRUTH WHEREOF, I have hereunto affixed my signature

this __________, 2023 at__________, ____________, Philippines.

________________
Affiant
ID. No.

SUBSCRIBED AND SWORN to before me this ___ day of

_____________ at _______, ___________, Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2023.