Republic 

of the Philippines )
Province of Cavite )S.S.
Trece Martires City )
 

AFFIDAVIT OF LOSS 

I, ________________________, of legal age, Filipino citizen, single, and a resident of

________________________, having been duly sworn in accordance with law, hereby
depose and state:

1. That I am the holder of Passbook issued by ________________________;

2. Unfortunately, the above said Passbook was lost or missing for the reason of it was
misplace in my residence due to my poor safekeeping;
3. That despite diligent search and efforts to locate the said Passbook, I could not find
the same such that I now believe that they are now lost beyond recovery.
4. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing facts, moreover serve all legal intents.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of June 2021 at Trece
Martires City, Cavite, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me in the Trece Martires City, Cavite,

Philippines, this 3rd day of June 2021, who has satisfactorily proven to me her identity
through her ________________________ bearing the number
________________________, that she is the same person who is personally signed before
me the foregoing Affidavit of Loss and acknowledged that she executed the same.

Doc. No. : ______

Page No. : ______
Book No. : ______
Series of : 2021