REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ORIENTAL MINDORO )

CITY OF CALAPAN ) S.S

AFFIDAVIT OF LOSS

I, ANGELIE Y. BALMES, _____ years old, Filipino, and a resident of Barangay

Lumangbayan, San Teodoro, Oriental Mindoro after having been duly sworn in accordance with
the law under oath, hereby depose and say that:

1. I am the owner of a passbook issued by ________________________ (bank);

2. Sometime on November 2021 at ________________________ (saan nawala), and
while under my possession, care and custody, such passbook was lost;
3. That diligent effort were exerted to locate, retrieve, repossess, restore and save the
same proved futile, ineffectual, unsuccessful and fruitless;
4. I executed this affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of March 2023 at
City of Calapan, Province of Oriental Mindoro, Philippines.

ANGELIE Y. BALMES
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of March 2023 at City of
Calapan, Province of Oriental Mindoro, Philippines after affiant exhibited to me her UMID
identification card bearing number ______________________ as competent proof of her
identity.