REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x----------------------------x

AFFIDAVIT OF LOSS

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

a resident of _______________________________, after having been duly
sworn to in accordance with law, depose and state THAT:

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

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

2. Sometime on ____________, the passbook of the above-mentioned account

was lost in the following manner:
___________________________________________________
___________________________________________________

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said
passbook, and to the best of my knowledge, the same is truly lost;

4. In view thereof, I now desire and hereby request ______ Bank to issue another
passbook in lieu of the lost one and I am willing to surrender the lost passbook
in the event that the same could be found;

5. As such, I am executing this affidavit to attest to the foregoing facts and to

support the application for the issuance of a new passbook in lieu of the one
which was lost.
 IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in Makati City, Metro Manila, Philippines.

____________________
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me

this ___________________ in _________________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.