REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF AGOO )S.S

PROVINCE OF LA UNION )
X----------------------------------------------------------------------------------X

AFFIDAVIT OF LOSS

I, TITO B. TORRES, of legal age, Filipino citizen, married and residing at Barangay
Gana, Caba, La Union after being duly sworn, hereby depose and state:

1. That I opened an account at BJMP Multi-Purpose Cooperative, Mindanao Avenue,

Quezon City, for which I was issued a passbook;

2. That when I needed and checked the said passbook in the place where I usually safe
keep it, the same could no longer be found. The said passbook might have been
misplaced;

3. That its whereabouts cannot be ascertained despite due and diligent search
undertaken;

4. That in view thereof, I am now requesting the BJMP Multi-Purpose Cooperative to

issue another passbook in lieu of the one lost;

5. That I undertake to surrender the said passbook in the event the same could be found;

6. That I hereby hold BJMP Multi-Purpose Cooperative free from any loss or damage
that it may incur by reason of or in connection with the issuance of a new passbook.

7. That I am executing Affidavit to attest to the truthfulness of the foregoing and for all
legal intents and purposes it may serve

IN WITNESS WHEREOF, I have hereunto set my hand this 5 th day of July 2020, in
the Municipality of Agoo, La Union, Philippines.

TITO B. TORRES
Affiant
ID No. ______________
SUBSCRIBED AND SWORN TO before me this 5 th day of July 2020, in the
Municipality of Agoo, La Union, Philippines. Affiant personally appeared before me.