REPUBLIC OF THE PHILIPPINES

CITY OF CALAPAN
PROVINCE OF ORIENTAL MINDORO

AFFIDAVIT OF LOSS

I, _______________________, of legal age, Filipino, single, and resident

of____________________, after being duly sworn according to law, hereby depose and state
that:

1. I am the registered owner of __________________ with account no. __________.

2. I am a holder of passbook with passbook no. 467722 issued by the Philippine Business
Bank.
3. I kept the said passbook at my file folder together with some other important
documents.
3. Sometime in September 28, 2022 , when I am about to locate the said passbook, I
could no longer find it and until now, the same passbook was not found.
4. Despite diligent efforts exerted, I could no longer locate, find or recover the passbook,
and to the best of my knowledge, the same is truly lost.
5. I am executing this Affidavit to attest to the truth of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________at

______________

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________, affiant exhibited to me

her Competent Evidence of Identity by way of __________________ issued at ______________
on
__________________.

Doc. No. ______;

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