Republic of the Philippines )

Province of Zamboanga del Sur )S.S.

Municipality of Mahayag )

AFFIDAVIT OF LOSS

I, LACRIMA P. MENDOZA , of legal age, Filipino, widow and a resident of Purok 7,

Poblacion, Mahayag, Zamboanga del Sur, after having been duly sworn to in accordance with
law, depose and state THAT:

1. I maintain a Savings Account with S/A No. _____________ with Paglaum

Multipurpose Cooperative with a credit balance of approximately Three Thousand Pesos.

2. Sometime on November 2016 the passbook of the above-mentioned account was

lost while I am riding a public vehicle.

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 Paglaum Multipurpose

Cooperative 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 TRUTH WHEREOF, I have hereunto set my hand this 29th day of December, 2016 at
Mahayag, Zamboanga del Sur, Philippines.

LACRIMA P. MENDOZA
Affiant

SUBSCRIBED AND SWORN TO before me on this 29th day of December, 2016 at the
Mahayag, Zamboanga del Sur, Philippines.

LORNA S. ESPINA
Municipal Mayor

Paid Under O.R 0028983

Issued on: December 29, 2016
Issued at: Mahayag, Zamboanga del Sur