FORM NO.

092

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 been duly sworn in
accordance with laws, hereby depose and state;

1. I am the registered owner/co–owner/transferee/mortgagee of the parcel of land

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

2. 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. No deed or other instrument affecting the property has been presented for
registration or if there is any, the nature thereof, the date of its presentation, the names of
the parties, to such deed or instrument and other information and requirements relating to
such registration are still to be accomplished and processed.

4. The owner’s duplicate certificate or co-owner’s duplicate is free from any

intentional alteration or erasures and irregularities.

5. The certificate of title is not the subject of litigation or investigation

administrative or judicial, regarding its genuineness and/or due execution.

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

7. The certificate of title is covered by Tax Declarations regularly issued by the

Assessor’s Office.

8. The real estate taxes have been fully paid up to at least two (2) years prior to
the filing of the petition for reconstitution.
(If the reconstitution is to be made from a co-owner’s duplicate the affidavit
should state this circumstance.)

9. The corresponding owner’s duplicate of the said Original/Transfer Certificate

of Title No/s. _________________was lost or destroyed in the possession of
____________________________ under the following circumstances:

(State below the circumstances)

_______________________________________________
_______________________________________________
_______________________________________________

10. The owner’s/co-owner’s duplicate of the title is being submitted as basis

for administrative reconstitution pursuant to Sec. 2 of Rep. Act No. 6732.
FN 092 . . . . . . . . 2

11. I am executing this affidavit in connection with my petition for administrative

reconstitution of the original copy of the Original/Transfer Certificate of Title No.
_______________________________ and attest to the truth of the foregoing

Further affiant sayeth naught.

__________________________
AFFIANT

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Jurat (NOTARY PUBLIC)