Republic of the Philippines )

City of Cagayan de Oro )

AFFIDAVIT OF LOSS

I, Rolan Mondragon Narandan, of legal age, Single, and a resident of Piaping

Puti, Macabalan, Cagayan de Oro City after being duly sworn according to law, do
hereby depose and state that:

1. I am the owner of the document:

FICCO LOAN PASSBOOK with Client ID No: 148454

2. On the 13th of July 2020, I discovered the loss of the said passbook under
the following circumstances:

I was about to put my passbook on my drawer upon arriving my office when

I discovered that the said item wasn’t with me anymore. It must’ve been
accidentally drop it when I get out of the car after pulling over at Osmeña
street.

3. Despite diligent search and best efforts, I failed to locate and recover the
said passbook to this day;

4. Wherefore, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to request for a replacement of the said passbook.

WITNESS WHEREOF, I have hereunto affixed my signature this 25th day

of September 2020 at Cagayan de Oro City, Philippines.

_____________________________
Rolan Mondragon Narandan
AFFIANT

SUBSCRIBED AND SWORN TO before me, this 25th day of September at

Cagayan de Oro City. The affiant Rolan Narandan personally appeared before me
and exhibited to me his Driver’s Licensed no. K02-18-007273 and is valid until
28th October 2022.

Doc. No. __________

Page No. __________
Book No. __________
Series of ___________