REPUBLIC OF THE PHILIPPINES.

)
PROVINCE OF SAMAR……………) SS.
CITY OF CATBALOGAN………..… )

AFFIDAVIT OF LOSS

I, LILIAN T. GABON, of legal age, single, Filipino and with present address at Patag
Poblacion 13, Catbalogan City, Samar, after having been duly sworn to in accordance with law
do hereby depose and state that:

1. I am a holder of Metropolitan Bank and Trust Company (MBTC) passbook

holder with account no. 007116510347;

2. Unfortunately, however, in September 15, 2021, said passbook which was

then contained in my bag was misplaced thereat; I then tried and exerted
efforts to locate the said passbook in every corner of places where I probably
placed it, but to no avail and the same proved futile such that after a
reasonable time that elapsed, I know consider it lost for all intents and
purposes;

3. The fact of loss is not intended to defraud the Metropolitan Bank and Trust
Company (MBTC) and third persons nor in perpetration of anything
unlawful, and I hereby absolve said offices of any liabilities or
responsibilities arising from said loss;

4. I am executing this statement to attest the truth of all the foregoing, to request
for replacement of said passbook and for other legal purposes.

IN WITNESS WHEREOF, I hereunto affix my signature this 22 nd day of September 2021

at Catbalogan City.

LILIAN T. GABON
Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of September 2021 at

Catbalogan City, Samar, affiant exhibiting to me his Driver’s License ID No. H01-04-025759
valid until September 14, 2024