Republic of the Philippines)

) S.S.
x-----------------------x

AFFIDAVIT OF LOSS
I, ____________________, Filipino, of legal age, married and with
residence address at _____________________, Philippines, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I have Passbook account in Philippine National Bank (PNB)-

Aldeguer Branch, ______________________, under the name
________________________;

2. That sometime on _________________, the said Passbook which I left

and secured in my shoulder bag placed and kept inside my
room was no longer found there;

3. That despite diligent search and efforts to locate the said Passbook,
I could not find the same such that I now have reasons to
believe that it is now lost and can no longer be recover; and

4. As such, I am executing this Affidavit of Loss to attest to the truth

of the foregoing and to support my application for the issuance
of a new Passbook from PNB-Aldeguer Branch, in lieu of the one
that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 5 th day of

June 2020 at __________________, Philippines.

AFFIANT

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public

in and for City of Iloilo this ___________________. Affiant personally
came and appeared with abovementioned ID, bearing her photograph
and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty
of law to the whole truth of the contents of said instrument.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2020