REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
x-----------------------x

AFFIDAVIT OF LOSS

I, AGNES R. CHUA Filipino, of legal age, and a resident of Purok 13, Poblacion,
Prosperidad, Agusan del Sur, after being duly sworn to in accordance with law, hereby depose
and state:

1) That I am the same person executing this Affidavit;

2) That I am a depositor/account holder of FIRST CONSOLIDATED BANK-

Prosperidad branch, located at Prosperidad, Agusan del Sur;

3) That being a depositor of FIRST CONSOLIDATED BANK, I was issued with a

depositor's PASSBOOK for all my deposit and withdrawal transaction with the bank;

4) That I used to keep the above PASSBOOK inside my handbag, which I carry with me
wherever I go;

5) That it was only recently that I searched for the said PASSBOOK but I could no longer
find the same;

6) That despite diligent search and efforts to locate the PASSBOOK, the same could not be
found such that I now consider it lost beyond recovery; and

7) As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing, for
the re-issuance of such PASSBOOK and for any legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of June 2020 in
Poblacion, Prosperidad, Agusan del Sur, Philippines

AGNES R. CHUA
Affiant

SUBSCRIBED AND SWORN to before me this 25th day of June 2020 in Poblacion,
Prosperidad, Agusan del Sur, Philippines.

ATTY. MARCELIANO P. MONATO III

Notary Public Until 2021
Roll of Attorney No. 65377
I BP No. 1068338 December 27, 2018/IBP ADS
PTR No. 7336450/January 3, 2018/PTO ADS
MCLE Compliance No. VI-0017950

Doc. No. : 442

Page No. : 89
Book No. :7
Series of 2020