Republic of the Philippines)

Province of La Union) S.S

Municipality of Balaoan)

AFFIDAVIT
I, IMELDA L. OBAR, of legal age, Filipino, widow and a resident of Brgy. Patpata,
Balaoan, La Union, after having been duly sworn to in accordance with law hereby
depose and state:

1. I am a member of Nueva Segovia Cooperative with principal place of

business at Vigan, Ilocos Sur and branch office at Bauang, La Union;

2. That as a member of said cooperative, I am entitled to avail of a salary loan;

3. That to avail of said benefit, I am required to surrender my Automated Teller

Machine (ATM) card issued by Veteran’s Bank San Fernando City, La Union
Branch with Savings Account No. 0032634315100;

4. That I am surrendering the said ATM card to Nueva Segovia Cooperative

Bauang, La Union Branch in compliance to the requirements of said
cooperative for the availment of loan;

5. That I am executing this affidavit to attest to the truthfulness of the foregoing

and for all legal intents and purposes it may serve.

IN WITNESS WEHEREOF, I have hereunto set my hand this September 14,

2015 at Balaoan, La Union.

IMELDA L. OBAR
Affiant
UMID CRN-006-0105-3688-5

SUBSCRIBED AND SWORN to before me this September 14, 2015 at

Balaoan, La Union.

GILBERT R. HUFANA
Administering Officer
Public Attorney I
Public Attorney’s Office
As authorized by Section 41 of RA 9406