Republic of the Philippines )

)
x-------------------------------------x

AFFIDAVIT OF LOSS

I, , of legal age, Filipino, and a resident of Brgy. after having been duly sworn to in
accordance with law hereby depose and say:

That, I am the holder of a passbook issued by CHINA BANK , Branch

under Account No.

That, June 13, 2017, I found out that the said passbook was lost/misplaced
and nowhere to be found;

That I exerted diligent efforts to locate the same but everything proved
futile;

That I am executing this affidavit in order to inform the CHINA BANK of

the loss of said passbook and to request the same for issuance of another
passbook in lieu of the lost ones, and for whatever legal intents and purposes it
may serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN TRUTH OF THE FOREGOING, I have hereunto set my hands this 19 th day of June
2017 here at
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of June 2017, here at