Republic of the Philippines }

City of Cagayan de Oro } S.S

x-------------------------------------x

AFFIDAVIT OF LOSS

I_________________, of legal age, Filipino and with residence at 29

Nacabalan St., Brgy. 20, Cagayan de Oro City, after having been duly sworn to
in accordance with law, do hereby depose and state that:

1. I maintain an account with ____________ with _____________ with which I

was also issued a passbook;

2. Two (2) weeks ago, said passbook has been misplaced and its
whereabout cannot be ascertained despite due and diligent search
made, such that I now believe that the same is lost beyond recovery;

3. In view thereof, I now desire and hereby request Oro Integrated

Cooperative to issue another passbook in lieu of the lost one and I am
willing to surrender the lost passbook in the event that the same is
found;

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

foregoing facts and to support my application for the issuance of a
new passbook in lieu of that which is lost.

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

May 2021 in Cagayan de Oro City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of May 2021, in

Cagayan de Oro City, affiant exhibiting to me her ______________________ as her
competent evidence of identity.

Doc. No.
Page No.
Book No.
Series of 2021.