REPUBLIC OF THE PHILIPPINES )

CITY OF ILAGAN ) S.S

PROVINCE OF ISABELA )
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AFFIDAVIT OF LOSS

I, OLIVIA D. APALLA, Filipino, of legal age, married and with

residence at Capitol Hills, Alibagu Ilagan, Isabela, Philippines, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I maintain a Passbook Savings Account in MRI RIZAL

BANK INC. with an approximate credit balance of Five
Thousand Pesos (P5,000.00);

2. That on or about 9:30 in the morning of April 17, 2019, the

Passbook of the above-mentioned account, was lost and its
whereabouts cannot be ascertained despite due and diligent
search made and undertaken such that I now believe that the
same is lost beyond recovery;

3. That I now request the MRI RIZAL BANK INC.to issue a new
Passbook/Certificate in lieu of the lost one and I bind myself to
surrender the lost Passbook/Certificate in the event that the
same is found and/or located;

4. That I covenant to indemnify MRI RIZAL BANK INC. for any loss
and damage it may incur by reason of its issuance or
replacement Passbook/Certificate;

That I am executing this affidavit to attest to the veracity of the

above-stated facts, for the purpose of the issuance of a new
Passbook/Certificate or any other legal purpose which this affidavit may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day

of July 2019 at Ilagan City, Isabela.

OLIVIA D. APALLA
Affiant

SUBSCRIBED and SWORN to before me this 1st day of July

2019 at Ilagan City, Isabela by affiant who exhibited to me her GSIS
UMID ID No. 006-0019-3211-3

ATTY. YULO VINCENT B. PANUNCIO, JR.

Public Attorney I
Administering Oath
Pursuant to RA 9406