REPUBLIC OF THE PHILIPPINES)

) S.S.
x- - - - - - - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I, ____________________, of legal age, Filipino, ____ and a resident of

________________________________________, after having been duly
sworn, in accordance with law, depose and say:

1. That I am the owner and holder of

_________________________________ with account numbers and
serial numbers ____________________________;

2. That I __________________________________________; Thus, in

_________________________________________________________
;

3. That ____________________________________________________;

4. That I exerted diligent effort to recover the missing passbook but my

efforts proved to be futile;

5. That the said _______ was not pledged, mortgaged or sold to the other
person;

6. That I attest to the truth of the foregoing and I have to execute this
affidavit to inform the authorities concerned of the aforementioned
facts and for whatever legal or lawful purpose the same may serve.

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

this ______________________ at ____________________________.

_______________________
Affiant
CEI: ____________________
With No. __________________

SUBSCRIBED AND SWORN to before me on the place and date above

mentioned.

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