REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LA UNION ) Sc.

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

AFFIDAVIT OF LOSS

I, PERLA V. MONTEMAYOR, of legal age, widow, Filipino and a resident of

Magsaysay, Tubao, La Union, after having been duly sworn to in accordance with law, do
hereby declare and say that:

1. My late son, NORANJO V. MONTEMAYOR, was a depositor of Tubao

Multipurpose Cooperative, located at Francia Sur, Tubao, La Union and
thereupon, he was issued a green passbook;

2. I tried to search for his passbook in order to present it to the TMC in order to
process his death/saranay benefits;

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

4. I undertake to surrender the said passbooks in the event the same could be
found;

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

foregoing narration of facts and for whatever legal intents and purposes this
may well serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of June 2023 at
Tubao, La Union, Philippines.

PERLA V. MONTEMAYOR
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of June 2023 at Tubao, La
Union by the affiant appearing personally and who is known to me to be the same person who
executed this affidavit.

ATTY. JOONEE RANDYL E. RIVERA

Notary Public until December 31, 2024
Doc. No.: 24; Aspiras Highway, Francia Sur, Tubao, La Union
Page No.: 6; 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