Republic of the Philippines )

Province of Laguna ) Sc.

City of Calamba )

AFFIDAVIT OF LOSS
I, Rosie Abesamis Ramos, Filipino, 65 years old, married, with residence and
postal address at 291 Don Bosco St., Brgy. Mayapa, Calamba City, Laguna, after
having been duly sworn to in accordance with law hereby depose and state that:

1. I am the lawful holder of Passbook issued by Plan Bank, Canlubang, Calamba City,
Laguna;

2. Sometime in October 2013, I decided to deposit a considerable amount of money to my

bank account however when I looked for it inside my bag where the same is being kept,
I found it to be missing;

3. I and my daughter took pains to look for said Passbook but to no avail hence, I
considered the same to have been lost;

4. I am executing this affidavit to attest to the truth of the foregoing and to request from
Plan Bank to replace the said Passbook.

IN WITNESS WHEREOF, I have hereunto set my hand this 3 rd day of December,

2013 at Calamba City, Laguna.

Rosie A. Ramos
Affiant

SUBSCRIBED AND SWORN to before me this 3 rd day of December, 2013 at

Cabuyao City, Laguna with affiant exhibiting her Senior Citizen ID No. 08456 issued on
June 2, 2008 at Calamba City as competent evidence of her identity.

ATTY. MICHAEL L. ASUTEN

NOTARY PUBLIC
Notarial Commission 2013-10
Doc. No. ______ For and in the Province of Laguna
Page No. ______ Until December 31, 2014
Book No. ______ PTR No. 0065500/ 564-1-05/ May 30, 2013
Series of ______ Cabuyao City, Laguna
Roll No. 62627
IBP No. 934907