REPUBLIC OF THE PHILIPPINES)

CITY OF GENERAL SANTOS…….) S.S.

X-----------------------------------X

AFFIDAVIT OF LOSS

I, JANE MARIE P. PASILABAN, Filipino, of legal age, and a resident of #34 1ST
Street Soriano Brgy. City Heights, General Santos City, after being duly sworn to in
accordance with law, hereby depose and say:

1. That I opened a savings account with Security Bank and was issued a
Security Bank Passbook bearing the Bank Book Account Number 000 000 319
0309;
2. That I had the said passbook safe-kept inside a drawer in our house for safe-
keeping and easy future reference;
3. That lately, I intended to retrieve it from where it was safe-kept but the
same was lost;
4. That despite diligent efforts to locate and retrieve the said Passbook, the
same could no longer be found and is now beyond recovery;
5. That I execute this affidavit to attest to the truth of the foregoing for all
legal purposes.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this __________________, in

General Santos City, Philippines.

_____________________________
JANE MARIE P. PASILABAN
Affiant

SUBSCRIBED AND SWORN TO before me this __________________________, in

General Santos City by affiant who exhibited to me her valid ID: Driver’s License No. L04-
09-007064.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2023.