REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )
MUNICIPALITY OF __________ )S.S.

AFFIDAVIT OF LOSS

I, ADELAIDA K. GRIFALDA, of legal age, Filipino, with residence

address at Brgy. San Jose, Pangil, Laguna, after having been sworn in accordance
with law, hereby depose and state:

1. That I maintain a Savings Account with Rural Bank of

Pangil, Inc., Pangil, Laguna with No. 001-01-010453-0. As such, I was
issued a passbook.

2. That I had been keeping the said passbook inside my

bag. However, recently, I noticed that the same is missing. I may
have misplaced the same.

3. That I exerted diligent efforts to locate the said passbook

but to no avail. Hence, I am considering it as lost for all intents and
purposes.

4. That I now desire and hereby respectfully request the

Rural Bank of Pangil, Inc., Pangil, Laguna to issue a new passbook in
lieu of the one lost.

5. That I am willing to surrender the lost passbook in the

event the same is found and located. I bind myself to hold the Bank
free and harmless from any loss or damage that may arise or it may
incur in connection with the issuance of a new passbook.

6. That I execute this Affidavit to attest to the truth of the

foregoing facts and for whatever legal intents and purposes this may
serve.

Signed this ____ day of _______________ in _______________.

ADELAIDA K. GRIFALDA
Affiant
UMID No. CRN-0003-8206262-7

SUBSCRIBED AND SWORN to before me this _____ day of

____________________ in ______________________, affiant personally known to
me to be the same person who executed this Affidavit.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of _______.