Republic of the Philippines )

Province of South Cotabato ) S.s.

City of Koronadal )

AFFIDAVIT OF LOSS

I, LERMA G. ARROJO, a Filipino, of legal age, and a resident of Brgy.

GPS, Koronadal City, South Cotabato, Philippines, after being duly sworn to an
oath, depose and state:

1. THAT I am a holder of a passbook issued by RCBC – Surallah for

Savings Account No. 0000009004399841;

2. THAT I recently discovered that said passbook is no longer at the

usual place where I kept the same;

3. THAT diligent search was done in the same in places where I usually
keep my valuables at home, inside the drawers where I place my documents,
and in other places where I could have possibly left it, to no avail;

4. THAT said passbook was never used as collateral to obtain a loan from
private or government financial institutions;

5. THAT I now consider the said passbook as lost for all legal intents and
purposes;

5. THAT I desire and request RCBC - Surallah to issue a new passbook

in lieu of the lost one; that I undertake to surrender the lost passbook in the event
that the same will be found or located; that I bind myself to hold the bank free and
harmless from any loss or damage that may arise or may incur in connection with
the issuance of a new passbook; that each and all of the facts herein stated are
true; and that I am willing to testify before any court of law to substantiate the
truth of each and all of the above facts;

FURTHER AFFIANT SAYETH NOUGHT.

IN WITNESS WHEREOF, I have hereunto set my hands this

________________ at Koronadal City, South Cotabato, Philippines.

LERMA G. ARROJO
Affiant
Senior Citizen’s ID Control No. 18270
Issued on 01-09-14
Issued by OSCA – Koronadal City

SUBSCRIBED AND SWORN to before me this ___________________ at Koronadal

City, South Cotabato, Philippines by the affiant who exhibited to me the foregoing ID indicated
above, with her photograph and specimen signature reflected therein, a competent evidence of
identity required by law.

Doc. No. _____

Page No. _____
Book No. _____
SERIES OF 2020