REPUBLIC OF THE PHILIPPINES )

BULA, CAMARINES SUR ) S.S.

AFFIDAVIT OF LOSS
I, TERESITA S. TABAYAG, of legal age, Filipino citizen, married, with residence
and postal address at San Miguel, Bula, Camarines Sur, after having been sworn to
in accordance with law, hereby deposes and says that:

1. I am an active member of CARD BANK and likewise a holder of a

PASSBOOK MAAGAP SAVINGS issued by the same bank;

2. Said PASSBOOK MAAGAP SAVINGS was in the name of my daughter, LORY

JANE S. TABAYAG, the affiant being the ITF specifically indicated thereat;

3. However, I recently discovered that the said PASSBOOK MAAGAP SAVINGS

was missing and nowhere to be found, thus, considered lost;

4. Despite diligent efforts exerted to locate the said item, the same could no
longer be found and now considered lost and beyond recovery;

5. I want to inform the key personnel of CARD BANK - Bula SHINE 2 that said
PASSBOOK MAAGAP SAVINGS was inadvertently lost, thus, I now desire and
request CARD BANK - Bula SHINE 2 to issue a new Passbook in lieu of the one
lost;

6. I am willing to surrender the lost Passbook in the event that the same could
be found and located after the execution and submission of this Affidavit;
and

7. I am executing this Affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes this document may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________ at Bula, Camarines Sur, Philippines.

TERESITA S. TABAYAG
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at Bula,

Camarines Sur, Philippines, by the affiant, after presenting to me her proof of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019