Republic of the Philippines )

__________________________) S.S.
__________________________)

AFFIDAVIT

married and a resident of

I, ________________________________, of legal age, Filipino, ___________
_____________________________________________, after having been duly sworn to in accordance with law, hereby
depose and say:

That ______________________ obtained a loan from the closed ________________________________, presently

under Liquidation by the Philippine Deposit Insurance Corporation for the sum of ___________________ on
_____________________;

That as security to the aforesaid loan, ______________________ executed a real estate mortgage in favor of the
closed ________________________________ covering my/our property located at
________________________________________ which is more particularly described under TD No.
_________________________________ of the Municipal Assessor of Silang, Cavite;

That by virtue of the encumbrance, the same was annotated on TD No/s. __________________ as Entry No.
_______________________ with an inscription date of _______________________;

That the aforesaid loan was fully paid sometime in ___________________ but unfortunately, all receipts of
payment were lost because _____________________________ and cannot be located despite diligent effort to locate the
same;

That if these lost receipts are found later on, I/we undertake to deliver the same to the closed
__________________________ or to PDIC for verification and I/we hereby further agree to hold the closed
____________________________ and PDIC free and harmless from any claim, loss or damage that may arise from the loss
or unauthorized use of said receipts. That I/we hereby further agree to indemnify the closed
__________________________ and/or PDIC in the event that the receipts are found false or fraudulently issued. Should
the closed ___________________________ and/or PDIC incur any loss or damage from my/our representation hereof, I/we
hereby agree to indemnify them for the same, in addition to my/our other liabilities, civil or criminal, that may arise
therefrom;

That ________________________ was not able to immediately work on the cancellation of the aforesaid real
estate mortgage because ______________________________________________________;

That ______________________ have no outstanding obligation with the closed

______________________________ and if it should have been discovered that _______________________have unpaid
obligations with the bank, I/we undertake to pay the same to the closed ______________________________;

That I/we am/are executing this affidavit to secure a release/cancellation of real estate mortgage from the
Liquidator of the closed ________________________________ and to attest to the truth and veracity of the above
allegations.

IN WITNESS WHEREOF, I/we have hereunto affixed my/our signature on this _______ day of
_______________________ at Silang, Cavite.

___________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, in ______________________ this _______day of

_____________________ at Silang, Cavite. Affiant exhibited to me his Senior Citizen’s I.D. bearing No. as proof of his
identity.