REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ILOCOS NORTE)

Paoay, Ilocos Norte) SS.

AFFIDAVIT OF LOSS

I, , Philippines after having been duly sworn in accordance with law, hereby
deposes and states that:

1. I am one of the heirs of

2. That is the declared owner of a parcel of lot under Original Certificate

of Title specifically described as follows:

3. That prior to the death of late, she designated as my mother’s

inheritance the lot covered by;

4. That the was given by the late Adriana Bulong to her daughter, my
mother, That Adriana Bulong died on September 25, 1980;

5. That passed the possession of the aforesaid to me and was kept by me in

a long brown envelope in my old cabinet “lakasa” inside my room on the
groundfloor of our house;

6. That on September 7, 2018 the country was devastated by the Typhoon

Ompong, the northern part of the country was highly damaged because of the
fierce wind and heavy rain of the said typhoon;

7. That when Typhoon Ompong land fall in Northern Luzon, our house
was damaged and was flooded due to heavy rain;

8. That after Typhoon Ompong left the Philippines, we started to fix and
repair the damaged it caused in our house, it was when I learned that all the
documents placed in my old cabinet “lakasa” inside my room on the
groundfloor of our house were completely soaked with flood water;

9. I tried to save the said title but the damaged caused by the flood was
beyond repair;

10. It is only now that I am declaring its loss due to financial reason because
it needs a lot of resources in securing another copy of the title;

11. Further, I am attesting that said TCT or the lot was not ceded, sold,
transferred or conveyed to anyone;

12. I am therefore executing this affidavit to attest to the truth of the

foregoing, as well as for all legal purposes this may be worth.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ at , Philippines.