REPUBLIC OF THE PHILIPPINES)

C I T Y O F D A V A O

) S.S.

AFFIDAVIT OF LOSS
I, _________________________-, of legal age, married and a resident
of __________________________________, Davao City , after having been
duly sworn to in accordance with the law, hereby depose and state that:
1. I am the authorized agent of ___________________________ by virtue of
the Special Power of Attorney, A copy of which is hereto attached as
Annex A;
2. I am duly authorized to execute this Affidavit of Loss for and in
behalf of the _____________________s;
3. The ______________________ are the owners of a real property covered by
____________________situated at No______________________________ Davao
City, Philippines;
4. There used to be a house which was constructed in the abovementioned address and it was only their father, _____________________,
who was living in the said house;
5. _________________________________, A fire gutted down the house and
their father died during the said unfortunate incident. The owners
duplicate of _________________________________ was with their fathers
possession at the time of his death and because of fire, the same was
destroyed;
6. I am executing this affidavit to attest to the truth of the foregoing and
to request from the Register of Deeds of of Davao City, a certified copy
of said Certificate of Title..
IN WITNESS WHEREOF, I have hereunto set my hand this
_______________________________ at Davao City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me ________________________ at

Davao City, Philippines.

Notary public