AFFIDAVIT OF LOSS TITLE

I, CAROLINA GACOSTA, of legal age, single, Filipino, and a resident of _____, Talisay City, Cebu,
Philippines, after being sworn in accordance with law, hereby depose and state—

1. I am the purchaser / vendee of that parcel of land located at Barangay Taloot, Argao, Cebu
containing an area of Six Hundred Fourteen (614) covered by Transfer Certificate of Title No.
T-____ of the Registry of Deeds of Cebu Province—as evidenced by the Deed of Sale of a
Registered Land which was executed in my favor by Manuel D. Patalinghug married to
Consolacion B. Gacosta and thereupon acknowledged before Notary Public _________ and
docketed in his Notarial Registry as “Doc. No. ____; Page No. ____; Book No. ____; and
Series of ____.” A copy of the said Deed of Sale of a Registered Land is hereto attached and
made an integral part hereof as ANNEX A.

2. Immediately after the Deed of Sale of a Registered Land was executed, the original duplicate
owner’s copy of Transfer Certificate of Title No. ______ was turned over to me by Manuel D.
Patalinghug. He likewise delivered to me possession the subject parcel of land and since then I
have openly exercised and maintained all rights of ownership thereon.

3. That quite of accident, on the ____ th day of _______, _____, more or less, my envelop (folder)
fell from my hand while I was on my way to Argao, Cebu. That noted the loss only when upon
reaching my destination, I saw that folder was gone, together with my TITLE TCT. No. T-
44570 but to no avail;

4. I certify and confirm that the parcel of land covered by Transfer Certificate of Title No. ______
of the Registry of Deeds of Cebu Province was never mortgaged, sold, conveyed, disposed of,
or encumbered, to any other person or entity. I certify and confirm further that said document
was neither confiscated nor relinquished in favor of, any government entity agency, or authority.

5. I attest to the truth of the foregoing statements to the best of my own personal knowledge and
based on authentic documents or records. I am executing this Affidavit of Loss to support my
application for a new owner’s duplicate copy of Transfer Certificate of Title No. ______ as well
as for all lawful intents and purposes it may serve.

IN TRUTH WHEREOF, I have here unto set my hand this 1st day of March, _______________
at Minglanilla, Cebu.

CAROLINA GACOSTA
(Affiant)
__________________________
Issued at __________________
On __________________, 2013

SUBSCRIBED AND SWORN to before me this __________th day of __________________,

_____________ Affiant, who exhibited to me his ____________ indicated below the name and
signature issued at ____________________.
Doc. No. _______________;
Page No. _______________;

Book No. ______________;

Series of 2019;