REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ISABELA ) S.S.

MUNICIPALITY OF JONES )

AFFIDAVIT OF LOSS OF PASSBOK

The undersigned Clifford T. Domingo, of legal age, single and residing at

Barangay II, Jones, Isabela, after having been duly sworn to according, hereby
depose and say:

1. That on or about year 2024 she opened a Passbook Savings Account with
the Philippine National Bank- Santiago City Branch as shown under Account No.
_________________________ which was in her possession since 2013;
2. That the credit balance appearing on the said Passbook Savings Account
No. _______________ as of March 2024 is PHP 168, 000.00 more or less;
3. That on or about May 30, 2024 the said Passbook Card No.
_________________ was lost in the following manner:

Misplaced and cannot find despite diligent efforts to locate the same;

4. That in view thereof, she now desires and hereby request PNB to issue
another passbook Card in lieu of the lost one and she is willing to surrender the
lost passbook Card in the event that same could be found;
5. That she binds herself to save PNB harmless from any loss or damage that
it may incur in connection with the issuance of a new passbook Card in lieu of the
lost one;
6. That each and all of the facts herein stated are true and she is willing to
testify before any court of justice to substantiate the truth of each and all of said
facts.

IN WITNESS WHEREOF, I have hereunto sat my hand this 1st day of June,
2024, at Jones, Isabela, Philippines.

CORAZON S. PELAGIO
SC ID NO.: 24-3316
Affiant

SUBSCRIBED AND SWORN to before me this 1st day of June 2024 in Jones, Isabela,
affiant.

WITNESS MY HAND AND SEAL..

Doc. No. 493;

Page No. 100;
Book No. 01;
Series of 2024.