REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ORIENTAL MINDORO )S.S.

MUNICIPALITY OF ROXAS )
X----------------------------------------------------X

AFFIDAVIT OF LOSS
I, ROCKY ORQUIA ASTOVEZA, Filipino, of legal age, married and with
residence and postal address at Palayan, Paclasan, Roxas, Oriental Mindoro, after
having been duly sworn in accordance with law hereby depose and state:

1. That I am a bona fide member of CARD BANK INC. Center 3, Palayan,

Paclasan, Roxas, Oriental Mindoro with office address at Bagumbayan,
Roxas, Oriental Mindoro, and as such, I was issued a PASSBOOK with
CID No. 99481;
2. That sometime on October 21, 2021, I noticed that the said Passbook
was already missing;

3. That I took pains to look and locate the said Passbook but all my efforts
proved to be futile;
4. I further attest that I have not pawned Card Bank Passbook, as
collateral in any loan in any bank or lending institution, and that if it is
found that I have done so, I know and understand that I will be held
liable for perjury;
5. I am executing this affidavit to attest to the truth of the foregoing
statements and respectfully request the said agency to issue a new copy
of Card Bank Passbook in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto set my hand this 11 th day of

November 2021 at Roxas, Oriental Mindoro.

ROCKY ORQUIA ASTOVEZA

ID NO. 02-025908936-1
Issued at Philhealth Calapan City, Or. Mdo.

SUBSCRIBED AND SWORN to before me, this 11 th day of November 2021 at

Roxas, Oriental Mindoro.

ATTY. APPLE KRIS J. CHING

Public Attorney I
Pursuant to R. A. 9406