REPUBLIC OF THE  PHILIPPINES )

Tayabas City, Province of Quezon  ) SS.

AFFIDAVIT OF LOSS

I, MA. AILEEN A. AVERILLA, of legal age, married and with address at Blk
1, Lot 20, Intertown Homes, Tayabas, Quezon, after having been sworn to in
accordance with law, do hereby depose and state that:

1. I am the owner and holder of a passbook issued by Wealth Bank which was kept
at the above-mentioned residence;

2. I tried to look for the said passbook at my residence at I could not locate the
same;

3. I have tried earnest efforts to locate the whereabouts of my passbook but to no

avail;

4. I am executing this affidavit to attest to the truth of the foregoing and for
whatever lawful purpose this may serve;

Tayabas City, 21 August 2018

MA. AILEEN A. AVERILLA

Affiant

SUBSCRIBED AND SWORN TO before me this 21 st of August 2018, affiant

Ma. Aileen A. Averilla appeared in person, was identified by me through competent
evidence of identity by exhibiting to me her Identification Card with No. 0697919
issued by the Professional Regulation Commission and signed the said Affidavit of
Loss in my presence.

Notary Public

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