Republic of the Philippines}

City of Dipolog……..……….}s.s.

AFFIDAVIT OF LOSS

I, ANA JEAN M. BAGSICAN, Filipino, of legal age, married and a

resident of Purok-1, Brgy. Poblacion, Sibutad, Zamboanga del Norte, after having
been duly sworn to in accordance with law, do hereby depose and say, That:

1. I am the owner and holder of PAGLAUM MULTI-PURPOSE COOPERATIVE

CAPITAL BUILD-UP PASSBOOK and PAGLAUM MULTI-PURPOSE
COOPERATIVE SAVINGS PASSBOOK;

2. Sometime in August 2015, I discovered that the aforementioned Passbooks were

missing;

3. Despite diligent search and efforts to locate the said Passbooks, I could not find the
same;

4. I have not assigned nor encumbered the afore-said Passbooks; and

5. I am executing this affidavit to attest to the truth of the foregoing circumstances

and for all legal purpose and intent it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_________________ at Dipolog City, Philippines.

ANA JEAN M. BAGSICAN

Affiant
VIN: 7217-0003A-H2376AMB2000

SUBSCRIBED AND SWORN to before me this ____________________ at

Dipolog City, Philippines, by affiant who exhibited to me a valid proof of her
identity 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 2021.