Republic of the Philippines )

MUNICIPALITY OF STO. TOMAS )S.S.

Province of Davao del Norte )
x----------------------------------------x

AFFIDAVIT OF LOSS
I, VICTORIANNE RUTH T. CATIGAN, of legal age, Filipino, married and a resident of
Feeder Road #1, Brgy. Tibal-og, Sto. Tomas, Davao del Norte, Philippines, after having been
sworn to in accordance with law, do hereby depose and state that:

1. I am the same affiant who personally and voluntarily caused the preparation and
execution of this affidavit;

2. I have an existing savings account with TAGUM COOPERATIVE - Sto. Tomas

Branch, Davao del Norte, of which I had been issued a savings passbook;

3. Sometime on the 3rd of October, 2019, I discovered that the said savings passbook
was missing from my personal files at home where I usually kept the same;

4. I exerted earnest efforts to locate and recover the said savings passbook, yet, all
efforts proved futile and to no avail. Thus, I deemed it to be permanently lost;

5. I have neither sold, assigned, loaned nor transferred the said savings passbook or
any interest thereof of the funds represented thereby to any person, natural or
juridical, in any manner whatsoever;

6. This affidavit is executed as proof of such loss and request is hereby for the
issuance of new savings passbook in lieu of the lost one;

7. I am further executing this affidavit to attest to the veracity of the foregoing

declarations, to apprise the authorities concerned and for whatever legal purpose
this may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this October 14, 2019
at Sto. Tomas, Davao del Norte, Philippines.

VICTORIANNE RUTH T. CATIGAN

Affiant
PRC Registration No. 1611699

SUBSCRIBED AND SWORN to before me this October 14, 2019 at Sto. Tomas,
Davao del Norte, Philippines.

Doc. No. 252;

Page No. 51;
Book No. 240;
Series of 2019.