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TO: ATTY.

________________
REGISTRAR OF DEEDS
REGISTER OF DEEDS OF _____________
___________ CITY REGISTRY
________________ CITY

VERIFIED NOTICE OF LOSS

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


_______________________.

_____________________
Affiant
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.

WITNESS MY HAND AND SEAL.


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