REPUBLIC OF THE PHILIPPINES )

CITY OF _____________________ ) S. S.

AFFIDAVIT OF LOST PASSBOOK

I/We, _______________________, Filipino, single/married, of legal age, resident of

______________________________, and _______________________, Filipino, single/married,
of legal age, resident of ______________________________, after being duly sworn according
to law, hereby depose and state that:

I/We have a Savings Account with the Bank of the Philippine Islands (the Bank),
_______________ Branch, under Account Name ____________________________, with
Savings Account No. _____________________, and for which Savings Account, Passbook No.
_____________________ has been issued to me/us;

On or about _____________________, in _____________________, the said Savings

Passbook was lost in the following manner:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
and its present whereabouts cannot be ascertained despite due and diligent search made and
undertaken therefor;

In view of the above, I/we hereby request the Bank to issue another Savings Account
Passbook to me/us, in lieu of the one that was lost, which should be considered as null and void
and duly cancelled, pursuant to the rules and regulations of the Bank;

I/We hereby undertake to surrender the said lost Savings Account Passbook No.
_____________________ in the event that the same should be found and located;

I/We hereby solidarily bind myself/ourselves to answer and fully compensate the Bank for
any loss or damage that it may incur or suffer in connection with the issuance of a new Savings
Account Passbook covering the present valid balance of PESOS: ____________________ ,
Philippine currency (P_______.00) of the account in question;

Each and all of the facts stated herein are true and correct; and

The undersigned are willing to testify before any court of justice to substantiate the truth
and veracity of each and all of the foregoing facts.

In case the account is a JOINT ACCOUNT:

Savings Account Passbook No. ____________________ is not in my/our possession or

of any of our co-depositor(s)';

There is no ongoing dispute between me/us and my/our co-depositors;

IN WITNESS WHEREOF, the undersigned has/have caused these presents to be

executed at _____________________, Philippines, on this _____ day of
_____________________, _______.

NAME(S) AND SIGNATURE(S) OF AFFIANT(S)

Effective Date: May 23, 2011
Subscribed and sworn to before me in _______________, on this _______ day of
________________________________________, affiant/s

NAME CTC No(s). Issued At/On Gov’t. issued ID No(s). Issued At/On

who is /are personally known to me and to me known to be the same person who executed the
foregoing instrument, exhibited to me his/her Community Tax Certificate; and / or who was
identified by me through competent evidence of identity to be the same person/s who executed
the foregoing instrument, exhibited to me his/her Government Issued ID.

Notary Public
My Commission Expires on ____________________
Commission Serial No. ________________________
Place of Commission __________________________
Office Address _______________________________
Roll No. _______________IBP No. _______________
PTR No._________ Place _______ Date ___________

Doc. No. _______;

Page No. ______;
Book No. ______;
Series of ______.

Effective Date: May 23, 2011