REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x----------------------------x

AFFIDAVIT OF LOSS

I, MARIFE OMNA RAMIREZ-PENAMANTE, of legal age, Filipino, MARRIED

and a resident of Purok Kamias, Brgy. Ungos, Real, Quezon, after having been
duly sworn to in accordance with law, depose and state THAT:

1. I maintain a Savings Account with S/A No. 11-5804-20 with QCRB Bank with
a credit balance of Eleven Thousand Two Hundred Sixteen pesos and Sixty-
one centavos only (P11,216.61);

2. Sometime on December 2016, the passbook of the above-mentioned account

was lost in the following manner:
I lost my bag which contain the said passbook and other documents.

3. Despite diligent efforts exerted, I could no longer locate, find or recover the
said passbook, and to the best of my knowledge, the same is truly lost;

4. In view thereof, I now desire and hereby request QCRB Bank to issue another
passbook in lieu of the lost one and I am willing to surrender the lost passbook
in the event that the same could be found;

5. 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.

IN WITNESS WHEREOF, I have hereunto set my hand this February

4, 2017 in Real, Quezon, Philippines.

MARIFE OMNA R. PENAMANTE

Affiant

GSIS ID No. _________

SUBCRIBED AND SWORN TO before me

this ___________________ in _________________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.