REPUBLIC 

OF THE PHILIPPINES)
MUNICIPALITY OF BACO                      ) S.S.
x-------------------------------------x
  

AFFIDAVIT OF LOSS 

         I, JERSON R. ZULUETA, of legal age, Filipino, single and a resident of

Alag, Baco, Oriental Mindoro, after having been duly sworn to in accordance with
law, depose and state:

1. That I am a holder of Passbook duly issued in my favor by Banco De Mindoro,

Inc. in Calapan City;

2. That I used to put said Passbook in my room;

3. That sometime on March 19, 2021, when I needed it, I discovered that said
Passbook was no longer in my room;

4. That diligent effort to locate the same proved futile;

5.  In view thereof, I now desire and hereby request Banco De Mindoro, Inc.
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 could be found;

6. As such, I am executing this affidavit to attest to the foregoing facts and

to support the application for the issuance of a new passbook in lieu of
the one which was lost. 

7. That I am executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

         IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of

March 2021 in Baco, Oriental Mindoro, Philippines.
          

Jerson R. Zulueta
Affiant
CTC No: 10450080
Date Issued: January 15, 2021
Issued at: Baco, Oriental Mindoro

    SUBCRIBED AND SWORN TO before me this 19th day of March

2021 in Baco, Oriental Mindoro, Philippines, affiant exhibiting to me his valid
proof of identification.

Reynaldo A. Marco
Municipal Mayor

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.