REPUBLIC OF THE PHILIPPINES

)
TARLAC CITY
) S.S.
x-------------------------------------------x

AFFIDAVIT OF LOSS
I, XXXXX, of legal age, Filipino, married, and a resident of P. Carmen St.,
Poblacion, San Isidro, Nueva Ecija, after having been duly sworn to in
accordance with law, depose and state that:
1. I maintain a Savings Account with S/A No. 200000124868 with Philippine
Resources Savings Banking Corporation Tarlac City Branch;
2. Sometime on or about July 2016, the passbook of the above-mentioned
account, which has always been in my possession, was lost and its
whereabouts cannot be ascertained;
3. Despite diligent efforts exerted, I could no longer locate, find or recover
the said passbook, and to the best of my knowledge, the same is truly lost
beyond recovery;
4. In view thereof, I now desire and hereby request Philippine Resources
Savings Banking Corporation Tarlac City Branch to issue another passbook
in lieu of the lost one and I am willing to surrender the lost passbook in the
event
that
the
same
is
found;
5. As such, I am executing this affidavit to attest to the foregoing facts and
to support the application for the issuance of a new passbook in lieu of the
one which was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of December in
Tarlac City, Philippines.

XXXXXX
Affiant
UMID CRN Redacted
SUBCRIBED AND SWORN to before me this 10th day of December 2016 in
Tarlac City, Philippines, affiant exhibiting to me her competent evidence of
identity by way of UMID CRN REdacted.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.