REPUBLIC OF THE PHILIPPINES)

__________________________________) S.S.

AFFIDAVIT

I, ___________, Filipino, of legal age, single and a resident of Batasan, Arayat,

Pampanga, after being sworn in accordance with law, hereby depose and state that –

1. I have an existing loan with the __________, a bank which has been
subject of closure and is now party to a pending lawsuit against Philippine Deposit
Insurance Corp. (PDIC) and Bangko Sentral ng Pilipinas (BSP);

2. Due to said closure, I am requesting the stoppage of deduction of my loan

amortization under the Automatic Payroll Deduction System;

3. I am thus executing this affidavit to affirm and certify that I will solely be
responsible and liable for any action the PDIC or ________ may undertake due to the
non-payment of my loan amortization on time;

4. Further, I am executing this affidavit to attest the truth and veracity of the
foregoing statements and for all legal intents and purposes it may serve.

Affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________ at

the _______

Affiant

SUBSCRIBED AND SWORN to before me, this ____ at _______, affiant

exhibiting to me her valid ID until ______ bearing her photograph and signature as
competent evidence of her identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.