Republic of the Philippines )

) S.S.

AFFIDAVIT OF LOSS
I, ____________________________, of legal age, Filipino, single/married,
and a resident of ___________________________________________________,
after having been duly sworn to in accordance with law, hereby depose and state that:

1. I maintain a Peso ____________ Account with Account

No. 063-01-000041 and a USD ___________ Account with Account No.
063-19-000035-8 with _____________ Bank.

2. Around the year _______,

_________________________________________________________
____ . As a result thereof, the passbook account of above mentioned
account was lost.

3. Corollary, despite diligent efforts exerted, I could no

longer find, locate, and recover the said passbook. Hence, I have the
reason to believe that it is now truly lost.

4. As such, I am executing this affidavit to attest to the

foregoing facts and to support the application for the issuance of a new
passbook in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my

signature this ___ day _________ of __________ 2018.

________________________________
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ____________ 2018,

affiant exhibited to me his/her Tax Identification Number _______________.

NOTARY PUBLIC
Until December 31, 20___

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2018.