Republic of the Philippines }

Province of Davao del Norte }s.s.

City of Panabo }

AFFIDAVIT OF LOSS

I, ARNULFO I. IBAÑEZ, of legal age, Filipino, married to MARILYN O. IBAÑEZ, and

a resident of Salvacion, Panabo City, Davao del Norte, Philippines, after having been duly sworn
to in accordance with law, do hereby depose and say:

1. That I the registered owner of a parcel of land described as follows:

A parcel of land (Lot 239-B-1, Psd-11-061205 Amd.), being a portion of Lot 239-B,
Psd-11-019167, situated in the Barrio of Poblacion; City of Panabo; Province of
Davao del Norte; Island of Mindanao. Bounded as follows: N., along line 3-4 by Lot
238, Psd-60302; on the E., along line 4-1 by Lot 239-B-2; on the S., along line 1-2
by Lot 239-B-6 all of the subd. plan; on the SW., along line 2-3 by Provincial Road.

2. That as proof of ownership of the above described parcel of land, I was issued by
the Registry of Deeds of the Province Davao del Norte Transfer Certificate of
Title No. T-200951;

3. That said certificate of title, while in my possession, was misplaced and could no
longer be located in spite of exerting efforts to locate it;

4. That said certificate of title is not in the possession of any creditor by reason of any
encumbrance or real estate mortgage of the parcel of land covered by the subject
certificate of title;

5. That I am executing this affidavit to attest to the truth of the foregoing facts and to
support the application for a new owner’s duplicate copy of Transfer Certificate of
Title No. T-200951.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

Panabo City, Davao del Norte, Philippines.

ARNULFO I. IBAÑEZ
Affiant
___ ID # ____________

SUBSCRIBED AND SWORN to before me this ________________ at Panabo City, Davao

del Norte, Philippines, affiant exhibiting the ID stated above as competent proof of identity.

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series of 2018.