Republic of the Philippines)

City of Malolos, Bulacan ) S.S.

x ------------------------------ x

AFFIDAVIT OF LOSS

I, NELSON DELA CRUZ ROBLES, of legal age, single, Filipino

and a resident of #339 Palmera St., Cofradia, City of Malolos,
Bulacan, under oath, depose and say:

1. That I am a lawful holder of a PASSBOOK with Savings

Account No. _______________________________ issued to me by the
Rizal Rural Bank in City of Malolos, Bulacan;

2. That on October 15, 2016, said PASSBOOK was misplaced or

left somewhere which I cannot recall despite diligent efforts to locate
it, I cannot find it anymore;

3. That the lost PASSBOOK was not borrowed by anyone from

me for any unlawful purposes whatsoever;

4. That I am executing this affidavit to vouch for the truth of the

foregoing and for all other intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto signed my name on

this instrument on this 3rd day of November, 2016 in the City of
Malolos, Bulacan.

NELSON DELA CRUZ ROBLES

Affiant

PERSONALLY APPEARED BEFORE ME, a Notary Public for

and in the Province of Bulacan, on this 3rd day of November, 2016, the
herein affiant who subscribed and sworn to the foregoing document
and who avows under the PENALTY OF LAW to the truth of its
contents.

I hereby certify that the affiant has been identified by the

undersigned Notary Public through Competent Evidence of Identity:
UMID No. CRN-006-0173-2939-4 which bears his picture and
signature.

WITNESS MY HAND AND SEAL.

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Series of 2016.