REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Sc.

MUNICIPALITY OF TUBAO )
x-------------------------x

AFFIDAVIT OF LOSS
I, CRISANTA MEDINA BASCO, of legal age, married, Filipino and a resident
of Pongpong, Sto. Tomas, La Union, after having been duly sworn to in accordance with
law, do hereby declare and say that:

1. I am a depositor of Tubao Multipurpose Cooperative (TMC), located at Francia

Sur, Tubao, La Union and thereupon, I was issued a green passbook;

2. I used to place the aforesaid Passbook in my cabinet drawer for safekeeping;

3. However, I discovered for the first time that the said Passbook was nowhere to
be found;

4. I exerted diligent efforts in searching the same but its whereabouts could no
longer be ascertained;

5. I hereby hold the Tubao Multipurpose Cooperative (TMC) free and harmless
from any loss or damage that it may incur by reason or in connection with the
issuance of a new passbook;

6. I am executing this Affidavit to attest to the truthfulness and veracity of the

foregoing narration of facts; in support for my application for replacement of
the above passbook; and for whatever legal intents and purposes this may well
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 23nd day of June 2023 at
Tubao, La Union, Philippines.

CRISANTA MEDINA BASCO

Affiant
Passport No. P5618068B

SUBSCRIBED AND SWORN to before me this 23nd day of June 2023 at Tubao, La
Union, Philippines. Affiant signed the document in my presence and avowed under penalty of
law to the whole truth of the contents of the foregoing document.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2024
Doc. No.: 117; Aspiras Highway, Francia Sur, Tubao, La Union
Page No.: 25; Roll No. 61766, TIN 929-347-628
Book No.: XLIII; PTR No. 7442264, 01-03-23, Tubao, LU
Series of 2023. IBP Life Member No. 012553; 01-02-14, SFLU
Commission No. 2022-93
MCLE No. VII-0004258, 07/21/21