Republic of the Philippines)

City of Tacloban ) s.s.

Province of Leyte )
x-------------------------------x

AFFIDAVIT OF LOSS

I, VIRGINIA R. POLINAS of legal age, married, Filipino and a resident of

Brgy. 88, San Jose, Fisherman, Tacloban City, after having been duly sworn to
in accordance with law do hereby depose and say;

1. That I am a member-depositor of CARD BANK, Tacloban City;

2. That as such I was issued a Certificate for being a stock holder of the
above-mentioned bank;

3. That unfortunately, the above-mentioned document was kept inside

my drawer, however, just recently when I was to make use of it I noticed that
the same could no longer be found believed to have been misplaced;

4. That despite diligent efforts to locate and retrieve said passbook, the
same could not be found hence, for all intent and legal purposes I considered it
lost and beyond recovery;

5. That I am executing this affidavit to attest the veracity of the

foregoing statements.

IN WITNESS WHEREOF, I have hereunto affix my signature this 13 th day of

September 2018 at Tacloban City.

VIRGINIA R. POLINAS
Affiant

SUBSCRIBED AND SWORN to before me this 13 th day of September 2018

at Tacloban City. Affiant exhibited to me her OSCA ID with No. 3524 issued on
September 7, 2018 issued at Villareal, Samar.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2018