Republic of the Philippines)

Province of Isabela) S.S.
City/Municipality of Jones) 
x--------------x

AFFIDAVIT 

I, , Filipino, of legal age, married, and with residence at Barangay 02, Jones,

Isabela, Philippines, after being duly sworn to in accordance with law, hereby depose
and state:

That, I maintain a Savings Account with with a credit balance of Twenty-Eight

Thousand Eight Hundred Seventy-Nine and 30/100 (Php 28,879.30);

That, on or about sometime on Jul, the Passbook of the above-mentioned

account, which has always been in my possession, 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;
 
That, I now request the Rural Bank of San Agustin, Inc. to issue a new
Passbook 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;

That, I bind myself to indemnify Rural Bank of San Agustin for any loss and
damage it may incur by reason of its issuance or replacement Passbook;

That, each and every fact herein stated is true and I am willing to testify before
any court of justice to substantiate the truth of each and all the said facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 23rd day of

August, 2019 at Jones, Isabela, Philippines.

KAREN R. ANOLING
Affiant

ACKNOWLEDGMENT

Republic of the Philippines)

Province of Isabela) S.S
City/Mun. of _____________) S.S.

BEFORE ME, a Notary Public, for and in _________________, this _______

day of August, 2019, personally appeared Karen R. Anoling, with Resident
Certificate No. 10089374, Issued in Jones, Isabela on January 2, 2019, known to me
to be the same person who executed the foregoing instrument and hereby
acknowledged to me that the same is her free and voluntary act and deed.
 Notary Public

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019.