REPUBLIC OF THE PHILIPPINES.

)
PROVINCE OF SAMAR………..) SS.
CITY OF CATBALOGAN……… )

AFFIDAVIT OF LOSS

I, ASTERIA G. ADLAO, of legal age, widow, Filipino and with present address at
Greenpark, Pasig City, after having been duly sworn to in accordance with law do hereby depose
and state that:

1. I was lawfully married to DOMINADOR S. ADLAO who passed away on 20

July 2021 at our residence aforementioned;

2. During his lifetime, however, my husband was a seaman on board ocean-going

vessels and therefore was a member of the Social Security System (SSS) and eventually a
pensioner after his retirement from the service;

3. It is recalled that his SSS monthly pension was regularly deposited thru time
deposit at the Philippine National Bank (PNB), Cainta Branch, Cainta, Rizal under account
number 0113066000010477, out of which the corresponding deposit slip was issued in his favor;

4. After the passing of my husband, Dominador S. Adlao, and after the onslaught of
typhoon Ondoy which flooded Metro Manila, I earnestly looked after his personal papers and
documents, including but not limited to said slip;

5. Unfortunately, despite the long lapse of time and earnest efforts exerted, the said
slip could no longer be found, hence, the same is hereby declared lost for all intents and
purposes;

6. The fact of loss is not intended to defraud the PNB and third persons nor in
perpetration of anything unlawful, and I hereby specifically absolve said PNB of any liabilities
or responsibilities arising from said loss;

7. I am executing this statement to attest the truth of all the foregoing, and for other
legal purposes.

IN WITNESS WHEREOF, I hereunto affix my signature this 22nd day of April 2022 at
Catbalogan City

ASTERIA G. ADLAO
Affiant

SUBSCRIBED AND SWORN to before me this 22nd day of April 2022 at Catbalogan
City, Samar, affiant exhibiting to me her OSCA ID No. 107866, issued by the LGU Pasig City
on 03 January 2018