Republic of the Philippines )

Quezon City ………………... ) S.S.

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

AFFIDAVIT OF LOSS

I, SUSAN R. BASCON, Filipino, of legal age, married, and is currently

assigned as Administrative Assistant VI at OJ1, GHQ, Camp General Emilio
Aguinaldo, Quezon City, Philippines, after being duly sworn to in accordance
with law, hereby depose and state:

1. That I am a bona fide member of Kitanlad Multi-purpose

Cooperative a maintains a passbook thereof;
2. That sometime on 2015, my passbook on the above-mentioned
Cooperative 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;
3. That I now request the Kitanlad Multi-purpose Cooperative to issue
a new passbook in lieu of the lost one and I bind myself to
surrender the lost passbook in the event that the same is found
and/or located;
4. That I agree to indemnify Kitanlad Multi-purpose Cooperative for
any loss and damage it may incur by reason of its issuance of the
replacement passbook;
5. That I am executing this Affidavit of Loss to attest to the veracity of
the above-stated facts, for the purpose of the issuance of a new
Passbook and/or for any other legal purpose/s which this affidavit
may serve.

IN WITNESS WHEREFO, I have hereunto set my hand this 30 th day of

April 2018 at Quezon City, Philippines.

SUSAN R. BASCON
Affiant

SUBSCRIBED AND SWORN to before me this 30 th day of April 2018 in

Quezon City. Affiant exhibited to me his Security I.D. with I.D. Control No.:
05-103

Doc. No._____;
Page No._____;
Book No._____;
Series of 2018.