Republic of the Philippines ]

Province of Negros Oriental } S.s.

City of Dumaguete ]

AFFIDAVIT OF MUTILATION
I, LUCINA F. MINDAC, of legal age, Filipino, widow and a resident of Dalakit, Poblacion,
Zamboanguita, Negros Oriental, Philippines, after having been sworn to in accordance with law,
do hereby depose and state that:

1. I am one of the daughters of GENOVEVO FLORES, married to JUANA P. FLORES

who is the registered owner of the parcel of land known as Lot 990, PLS-847 located
at Barrio of Mayabon, Municipality of Zamboangita, Province of Negros Oriental, and
covered by Original Certificate of Title No. FV-27592, by virtue of an instrument
called Deed of Extrajudicial Settlement of Estate with Deed of Sale dated
_________, which was entered in the Notorial Register of Atty. Al-zhain I. Sadjail, also
known as Doc No._______, Page No.________, Book No. __________, Series of
2018 hereto attached as Annex “A” to form an integral part of this Affidavit;

2. The owner’s duplicate copy of Original Certificate of Title No. FV-27592 covering
Lot 990, PLS-847, had been in my possession ever since the death of my father, but
recently, it was discovered that the owner’s duplicate copy of Original Certificate of
Title No. FV-27592 was eaten by termites inside the wooden cabinet which I placed
for safekeeping, and despite the diligent efforts to restore the same, it could no longer
be done as it has been reduced into powder form or very small pieces;

3. The owner’s duplicate copy of Original Certificate of Title No. FV-27592 covering
Lot 990, PLS-847 located at Barrio of Mayabon, Municipality of Zamboangita,
Province of Negros Oriental, has not been delivered to third persons or institution to
secure any financial obligation;

4. I am executing this affidavit to attest to the truth and veracity of the foregoing
declarations and to support my request for the issuance of a duplicate owner’s copy of
Original Certificate of Title No. FV-27592 covering Lot 990, PLS-847, and not for
the purpose of fraud.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ____
2018 at Dumaguete City, Philippines.

LUCINA F. MINDAC
AFFIANT

SUBSCRIBED AND SWORN to before me this ____ day of _____ 2018 at Dumaguete
City, Philippines Affiants exhibited to me her ________________________, bearing her
signature and photograph to be the same person who executed this instrument in my presence
and jurisdiction and avowed of the truth of the contents thereof under the penalty of law.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2018.