REPUBLIC OF THE PHILIPPINES )

CITY OF )S.S

AFFIDAVIT OF LOSS
I, BABY JANE P. DIAÑO, Filipino, of legal age, single, and with postal address at
Talon Amadeo Cavite after being duly sworn in accordance with law, depose and state:

1. That I am a holder of a bank passbook issued by CARD SME BANK;

2. That sometime on October 30, 2020, the said bank passbook 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 said bank passbook was not confiscated by an officer of the law or the officers
of CARD SME BANK by reason of any violation of law, ordinance, presidential
decree or rules and regulation of said bank; and neither was it offered as collateral for
any loan;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to request for a replacement of bank passbook from CARD SME BANK.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ____ 2021 at
Amadeo, Cavite, Philippines.

BABY JANE P. DIAÑO

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of _______ 2021 by the
Affiant whom I have identified through competent evidence of identity and who exhibited her
DSWD 4Ps ID 050512030-8886-00016 issued at _______ on ___________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.