REPUBLIC OF THE PHILIPPINES

CITY OF ____________________)
PROVINCE OF_______________)
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AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, (single / married / widow), and with

residence at _____________, Philippines, after being duly sworn to in accordance with
law, hereby depose and state:

That I maintain a Savings/Checking Account with S/A No. _____________ with

_____________ Bank with a credit balance of _____________ (P_____________);

That on or about _____________, the Passbook/Certificate of the above-

mentioned account, was lost and its whereabouts cannot be ascertained despite due and
diligent search made and undertaken such that I now believe that the same is lost beyond
recovery;

That I now request the _____________ Bank to issue a new Passbook/Certificate

in lieu of the lost one and I bind myself to surrender the lost Passbook/Certificate in the
event that the same is found and/or located;

That I covenant to indemnify _____________ Bank for any loss and damage it
may incur by reason of its issuance or replacement Passbook/Certificate;

That I am executing this affidavit to attest to the veracity of the above-stated facts,
for the purpose of the issuance of a new Passbook/Certificate or any other legal purpose
which this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _____ day of

_____________, affiant personally presented to me his _____ I.D. bearing I.D. No.
_________, issued/expiring on ________, at __________________, as competent and
valid proof of his identity.

Doc No. _____;

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