REPUBLIC OF THE PHILIPPINES )

Province/City_______________ ) SS.

AFFIDAVIT OF LOSS

I, xxx, of legal age and residing/with address at xxx, after having

been duly sworn on oath in accordance with law hereby voluntarily depose
and state:

1. THAT I am the wife of xxx whose name appears in an Original

Certificate of Title (OCT) No. xxx located at xxx with an area of xxx
(xxx) square meters issued by the Registry of Deeds of the Province of
xxx on xxx;

2. THAT quite an accident on the xxx, more or less, the envelope where
the aforesaid title was kept fell from my hand while I was on my way
to xxx, and I only noted the loss when upon reaching my destination, I
saw that the envelope was gone, together with the original copy of
TITLE with OCT No. xxx;

3. THAT I exerted diligent efforts to locate the original copy of the said
title but to no avail, therefore, I considered the same as lost and can
no longer be found;

4. THAT I am executing this Affidavit to attest to the truth of the

foregoing facts and to use the same for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I hereunto affix my signature this

_______________ at __________________.

xxx
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at

__________________, Affiant exhibiting to me her xxx bearing No.
xxxissued at the Municipality of xxx on xxx.

Doc. No. ________;

Page No. _______ ;
Book No. _______;
Series of 2022.