Republic of the Philippines )

City of Dasmariñas ………. ) S.S.

AFFIDAVIT OF LOSS

I, AAA, of legal age, Filipino citizen, single, and a resident of #546, Sitio Asiongan, Brgy. Langkaan I,
Dasmariñas City, Cavite, after being duly sworn to in accordance with law, hereby depose and state that:

1. I am the lawful owner in fee simple of real property covered by a Original Certificate of Title (TCT)
No. 127272 of the Registry of Deeds for the Province of Cavite, situated at Brgy. Langkaan,
Dasmariñas City, Cavite and the holder of a Duplicate Owner’s Copy of the land title in relation
thereto;

2. Informatively, I am customarily keeping the said duplicate owner’s copy of the land title inside my
cabinet at home which I have found to be safe and secured;

3. However, on December 2, 2019 at about 9:00 A.M., I was astounded and surprised to discover that
the above-described document was already missing and nowhere to be found at the place where it
has been kept;

4. Consequently, I have exerted diligent efforts to search for the said duplicate owner’s copy of the
said land title but the same proved futile as I have failed to locate it. As such, the Transfer
Certificate of Title of the above-stated real estate can now be considered as completely lost and
considerably beyond recovery;

5. I believed that the above-delineated item could have been accidentally and/or inadvertently
disposed of by me when my family has previously conducted a general cleaning at home;

6. By reason thereof, this Affidavit is being executed pursuant to the requirements of Section 5, of the
Republic Act No. 26 (An Act Providing a Special Procedure for the Reconstitution of Torrens
Certificate of Title Lost or Destroyed) and that I hereby attest under oath that no deed or other
instrument affecting the subject property had been presented for registration with the Registry of
Deeds for the Province of Cavite;

7. Moreover, not at any time, before or after the time of discovery of the loss, I have not allowed any
person to dispose of, encumber, mortgage or use as collateral the said Duplicate Owner’s copy, and
if in the remote event that any individual will come before the Honorable Office of the Register of
Deeds for the Province of Cavite for annotation of any transaction whatsoever, the same is
unauthorized, illegal and has not been allowed by the undersigned affiant.

8. In view of the foregoing, I am executing this Affidavit of Loss to attest to the veritableness of the
statements delineated on the above as well as for whatever legal intents and purposes this may
serve.

AFFIANT FURTHER SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ at

___________________, Philippines.

AAA
Affiant

SUBSCRIBED AND SWORN to before me, this __________________, by the affiant whom I have
identified through his ___________________ at __________________ which serves as his Competent Evidence of
Identity pursuant to the 2004 Rules on Notarial Practice.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.