Republic of the Philippines)

La Trinidad, Benguet) s.s

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AFFIDAVIT OF LOSS
I, ANGELY LUIS MA, of legal age, single, Filipino, and resident of Abatan, Buguias,
Benguet after having been duly sworn to in accordance with law, do hereby depose and state
THAT:

1. I was an account holder of a Passbook No. 4048-003-04-000151-1 duly issued by the

Benguet Center Bank, Inc., Abatan, Guinaoang, Mankayan, Benguet, our mother is
the one who safely kept the said Passbook together with my younger brother’s
Passbook inside our house purposely for safekeeping but it was no longer in our
possession because of the foregoing facts:

Sometime in December 2020, our mother has been searching and/or looking the
said Passbook purposely to update it with the Benguet Center Bank. However, our
mother noticed that said Passbook is nowhere to be found. It was there and then, she
immediately checked in the premises of the house to find the same. Unfortunately, she
discovered that said Passbook is no longer there or it was missing. Despite diligent efforts
exerted, we were not able to locate the afore-mentioned Passbook until now. Therefore, I
considered it lost and beyond recovery.

2. My said Passbook has neither been used for any illegal activities nor confiscated by
any government authorities but due to the afore cited reason;

3. I am executing this Affidavit to plead and request the Benguet Center Bank Inc., to
issue me a new Passbook in lieu of the lost one. That, I hereby bind myself to fully
excuse the bank for any damage that it may incur for the issuance of the requested
new Passbook;

4. Finally, I am executing this affidavit to attest to the truthfulness of the foregoing facts
and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 28th day of April
2021 at La Trinidad, Benguet, Philippines.

ANGELY LUIS MA
Affiant
TIN No. 738-010-108-000

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad,

Benguet, Philippines this 28th day of April 2021 by the above Affiant personally known to me of
her identity to be the same person who personally signed before me the foregoing Affidavit.

ATTY. CYRUS C. CALAYA

Doc. No. 1; Notary Public until Dec. 31, 2021
Page No. 2; PTR No. BGTCF 6233420; Jan. 4, 2021
Book No. III; IBP Lifetime No. 08051, at Pasig City
Series of 2021. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4
National, Highway La Trinidad, Benguet