Republic of the Philippines ]

City of Tagbilaran ] S. S.

AFFIDAVIT OF LOSS

I, NEMESIA M. NASAYAO, of legal age, Filipino, married and a

resident of Poblacion I, Sikatuna, Bohol, Philippines, after having been
sworn in accordance with law, depose and say:

1. That I am a holder of an account with the Katipunan Bank of

Bohol, Palma St., Tagbilaran City, Bohol;

2. That as such, I was issued a Savings Passbook by the said

bank;

3. That said Katipunan Savings Passbook was in my possession

but the same was lost / misplaced in an event and place
which I could no longer recall;

4. That I exerted diligent efforts to find and recover the

aforesaid Katipunan Saving Passbooks, however, my efforts
proved futile as until now, its whereabouts still could not be
ascertained, hence, I considered it to be lost for all intents
and purposes;

5. That the said Katipunan Savings Passbook was not transferred

to any person for consideration or used as collateral to secure
obligations;

6. That I execute this affidavit voluntarily to attest to the truth of

the foregoing statements and for whatever legal purpose this
may serve.

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

April, 2018 at Tagbilaran City, Bohol, Philippines.

NEMESIA M. NASAYAO
Affiant
SSS ID No. 03-4725263-4
Issued by SSS

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

2018 at Tagbilaran City, Bohol, Philippines.