Republic of the Philippines )

_____________________) s.s.
_____________________ )

AFFIDAVIT OF LOSS
(of Land Title)

I, GENINA MARTINEZ, of legal age, married, Filipino citizen and a resident of

_________________________________, Philippines, after having been sworn to on oath in
accordance to law, hereby depose and state that:

1. I am the absolute and registered owner of that parcel of land situated in

____________________________, under OCT/TCT/CLOA No. _________ denominated as
Lot No. ____________;

2. I kept said title in my cabinet for safekeeping and preservation. However, the original copy
of OCT/TCT/CLOA No. ______________ could no longer be located;

3. I exerted diligent efforts in locating said original copy, but all efforts proved futile, and I am
of honest belief that the same may have been misplaced and considered lost beyond recovery;

4. The said original copy of OCT/TCT/CLOA No. __________ was never used as collateral for
security or for any forbearance of money or any transactions involving conveyance, cession,
sale, donation or transfer of title over the said parcel of land;

5. I am executing this affidavit to attest to the truthfulness of the above-narrated facts in good
faith and in accordance with law and for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

_______________ in ____________________, Philippines.

GENINA MARTINEZ
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of _______________ in

_______________________, Philippines, by the affiant who is known to me on the basis of competent
documents shown as proof of her identity.