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REGISTER OF DEEDS OF _____________
___________ CITY REGISTRY
________________ CITY


I, _____________, of legal age, married, Filipino citizen and a resident of

______________________, under oath, depose and state that:

1. I am the registered owner of a certain parcel of land covered and embraced by Transfer
Certificate of Title No. ________ covering an area of ___________________ square meters
located at ______________. A photocopy of Transfer Certificate of Title No. _______ is
hereto attached and marked as Annex “A”;

2. Right after the same was issued to me by the Registry of Deeds, the same being a
Certificate of Land Ownership Award (CLOA), I safely kept the same in our residence;

3. However, sometime in the year ______, I needed money in order to cover the expenses of
my children in their studies. Hence, I decided to make a simple loan from __________
and the certificate of title was used as collateral thereof. It was agreed upon that the
loan shall be paid at any time whenever I already have the capacity to pay the whole
amount of loan without any interest thereof;

4. Sometime this __________, I informed ____________ of my intention to pay the whole

amount of the loan I made in order for me to recover the certificate of title.
Unfortunately, __________ informed me that he tried to locate for the certificate of title,
however, he could no longer locate the same;

5. According to ___________, diligent efforts were exerted in order to locate the possible
whereabouts of TCT No. _____, however, despite diligent efforts to locate the same, it
proved futile and presumed to have been totally lost. A copy of the Affidavit executed
by __________ is hereto attached as Annex “B”;

6. I am intending to file a petition for the issuance of a new owner’s duplicate of the said
Transfer Certificate of Title No. _______________ before the Regional Trial Court sitting at

7. I hereby notify your good office of the fact of such loss pursuant to Section 109 of
Presidential Decree No. 1529; and,

8. I hereby request your good office to register this notice in the manner provided by law.

IN WITNESS WHEREOF, I have hereunto set our hands this __________________ at


ID No.: __________________
Issued by: __________________

SUBSCRIBED AND SWORN to before me this this _________________ at _______________,

by the affiant who exhibited to me his competent evidence of identity as above-stated, who
signed in my presence the foregoing document, avowed to the veracity thereof and acknowledge
to me that it his free and voluntary act and deed.


Doc No.: _____;
Page No.: ____;
Book No.: ____;
Series of 2019.