Republic of the Philippines )

Done: ) S.S.
X-------------------X

AFFIDAVIT

I, ____________________________, of legal age, Filipino, widower, and with residence and

postal address at ________________________________, do hereby depose and state that:

1. I am the husband of _____________________, co-owner of a parcel of land situated at

______________ covered and embraced by Transfer Certificate of Title No. ____________ to
the extent of ONE HUNDRED TWENTY (120) SQUARE METERS, more or less;
2. The original owner’s duplicate copy of the above-mentioned title has been in the
possession of (co-owner), being the owner of a wider portion of the above-described
parcel of land and that it has never been in the possession of my wife or any of our
children nor in my possession;
3. We have no objection whatsoever to the petition for the issuance of a new TCT No.
____________________ in lieu of the lost one filed by (petitioner);
4. This affidavit is being executed to attest to the truth of the foregoing facts and for all
legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this (date) at (place),

Philippines.

______________________________________
Affiant
ID No. _____________
Issued/Expiring on _____________________
Issued at __________________________

SUBSCRIBED AND SWORN to before me this (date) at (place), Philippines, affiant

exhibiting to me her competent evidence of identity as indicated below her name and
signature, known to me to be the same person who executed the foregoing affidavit.

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