Republic of the Philippines)

) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, JOHNA R. AMBOY, of legal age, Filipino, married, and a resident of 22134

Saint John St. New Prodon Subd., Brgy. Gen. T. de Leon, Valenzuela City, after having
been sworn in accordance with law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of Parish of the Holy Cross Cooperative

Share Capital Passbook;

2. I have recently discovered that the said item is irretrievably lost and can no
longer be found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

IN WITNESS WHEREOF, I have hereunto set any hand this ____ day of
______________ 2019 at _____________.

SUBSCRIBED AND SWORN to before me on this ___ day of _____________ 2019

at ________________, affiant exhibited to me her _______________ issued at
__________________.

Notary Public

Doc. No.
Page No.
Book No.
Series of 2019.