AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________) S.S

I, _________________________________, Filipino of legal age, married/single/ widow/others and a

resident of _____________________________, Province of ___________________________ Philippines, after
having sworn in accordance with laws, hereby depose and state;

1. That I am the registered owner/coowner/transferee/mortgagee of the parcel of land covered by

Original/Transfer Certificate of Title No. _______________ of the Registry of Deeds of
_____________________________.

2. That the original copy of the aforesaid Original /Transfer Certificate of Title on file with the Registry of
Deeds _________________________ was lost or destroyed due to _____________________________.

3. That no deed or other instrument affecting the property has been presented for registration or if there
is any, the nature hereof, the date of its presentation, as well as the names to the parties and the registration of
such deed or instrument is still pending accomplishment.

4. That the owners duplicate certificate or co-owners duplicate is in due form without any intentional
alteration or erasures.

5. That the certificate of title is not the subject of litigation or investigation administrative or judicial, regarding
its genuineness of due executive or issuance.

6. That the Certificate of title was is full force and effect at the time it was lost or destroyed.

7. That the certificate of title is covered by Tax Declarations regularly issued by the Assessors Office.

8. That the real estate taxes have been fully paid up to at least, two (2) years prior to filing of the petition for
reconstitution.

(If) the reconstitution is to be made from a co-owners duplicate the affidavit should state.

9. That the corresponding owners duplicate of the said Original/Transfer Certificate of Title No/s.
_________________was lost or destroyed in the possession ____________________________ under the
following circumstances:

(State below the circumstances)

_______________________________________________
_______________________________________________
_______________________________________________

10. That the owners/co-owners duplicate of the title is being submitted as basis
for administrative reconstitution pursuant to Rep. Act No. 6732.
FN 079 . . . . . . . . 2

11. That I am executing the affidavit in connection with my petition for administrative reconstitution
of the original copy of the Original/Transfer Certificate of Title No. _______________________________.

Further affiant sayeth not.

__________________________
Petitioners Signature

SUBSCRIBED AND SWORN to before me this _____________ day of __________, 20_____ affiant exhibited
to me his/her Residence Certificate No. ___________. issued on ____________________ at
________________.

___________________________
NOTARY PUBLIC
Until ___________________

Doc. No. ________

Page. No. ________
Book No. ________
Series of 20 _______