(AFFIDAVIT OF LOSS) LEGAL FORMS

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, single and currently residing at #123 Paco, City of Manila, after
having been duly sworn in accordance with law, do hereby depose and state that:

1) I am the registered owner of that vacant parcel of land, with an area of 250 square meteres, situated at
456 Mapula St., Navotas City, covered by and more particularly described in TRANSFER CERTIFICAT OF TITLE
NO. N – 543210, of the REGISTER OF DEEDS OF NAVOTAS CITY.

2) On August 17, 2017, I had the original owner’s copy of the said certificate of title photocopied at a store
in front of the Navotas Public Market along M. Naval Street, Navotas City.

3) However, on my way home, I left the brown envelope containing the original owner’s copy of my said
certificate of title in the taxi cab I boarded in going home.

4) Despite diligent efforts, I was not able to recover the original owner’s copy of my said certificate of title.

5) I am executing this affidavit to attest to the truth of all the foregoing and for all legal intents and
purposes.

IN WITNESS HEREOF, I have signed this DEED OF SALE this 3rd day June, 2022, at the City of Manila

(Sgd.) Juan Dela Cruz

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 16th of June, 2022, in the City of Manila by Mr. with
LTO LICENSE NO. 4567, ISSUED ON: December 5, 2019, ISSUED AT: Manila City and with EXPIRY DATE
ON December 5, 2022.

(Sgd.) ATTY. JUAN DELA CRUZ

Notary Public for City of Manila
Appointment No. 456
Until December 31, 2022
Roll No. 12345; 4/20/2005
IBP No. 1234/ January 1, 2022/ City of Manila
PTR No. 1234/ January 1, 2022/ City of Manila

DOC. NO. 5
PAGE NO. 5
BOOK NO. V
SERIES OF 2022

By: Caffeinated Wisdom

Page 1