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REPUBLIC OF THE PHILIPPINES CITY OF ____________________) PROVINCE OF_______________) x-----------------------------------------/ AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, (single / married / widow), and with residence at _____________, Philippines, after being duly sworn to in accordance with law, hereby depose and state:

That I maintain a Savings/Checking Account with S/A No. _____________ with _____________ Bank with a credit balance of _____________ (P_____________); That on or about _____________, the Passbook/Certificate of the abovementioned account, was lost and its whereabouts cannot be ascertained despite due and diligent search made and undertaken such that I now believe that the same is lost beyond recovery; That I now request the _____________ Bank to issue a new Passbook/Certificate in lieu of the lost one and I bind myself to surrender the lost Passbook/Certificate in the event that the same is found and/or located; That I covenant to indemnify _____________ Bank for any loss and damage it may incur by reason of its issuance or replacement Passbook/Certificate; That I am executing this affidavit to attest to the veracity of the above-stated facts, for the purpose of the issuance of a new Passbook/Certificate or any other legal purpose which this affidavit may serve. IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.

Affiant SUBSCRIBED AND SWORN TO BEFORE ME this _____ day of _____________, affiant personally presented to me his _____ I.D. bearing I.D. No. _________, issued/expiring on ________, at __________________, as competent and valid proof of his identity. Doc No. _____; Page No. _____; Book No. _____; Series of _____.