REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG ) S.S.

AFFIDAVIT OF LOSS

I, Lope Culanag, of legal age, widower, Filipino Citizen, with

residence at South Mapang, Rizal, Zambonga del Norte, under oath
depose and state that:

1. I lost a Bank Book under my name with Rural Bank of Rizal

(ZN), Inc bearing the account no. 10x00104.

2. Such Bank Book was kept in our residence at Brgy Mapang,

Rizal, Zamboanga del Norte by my wife who unfortunately
died two years ago.

3. Since only my wife has knowledge of its whereabouts, I can

no longer locate the said Bank Book.

4. I have exerted diligent efforts to locate it, however my efforts

were proven to be futile.

5. I am executing this affidavit to comply with the requirement

for the issuance of another bank book.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I hereby set my hand this 8 th day of

January, 2018, in the City of Dipolog.

Lope Culanag
(Affiant)

SUBSCRIBED AND SWORN to before me this 8 th day of

January, 2018. Affiant exhibited to me his Voter’s ID with VIN: 7212-
0018A-I2555LBC10000 issued at Rizal COMELEC.
 NOTARY PUBLIC
Doc. No. ____________
Page No.____________
Book No. ____________
Series of 2018