REPUBLIC OF THE PHILIPPINES )

_______________________ ) S.S.

AFFIDAVIT OF LOSS

I, MA. CECILIA J. CELESTINO, of legal age, Filipino, married and a resident of 15B
Sabino St., Marulas, Valenzuela City, after having been duly sworn to in accordance with law,
depose and state:

1. That I am a holder of Passbook duly issued in my favor by Insular Savers Bank Inc. (formerly
Filipino Savers) in Quezon City.

2. That I used to put said passbook to a Folder intended for my important loan documents with
Insular Savers Bank Inc.

3. That yesterday while diligently looking for that folder I could not find the Passbook issued by
Insular Savers Bank Inc. The lost could have been due to our transfer of residence.

4. That in view thereof, I now desire and hereby request INSULAR SAVERS BANK INC. to
issue another Passbook in lieu of the lost one;

5. That I bind myself to save INSULAR SAVERS BANK INC. harmless from any loss or
damage that it may incur in connection with the issuance of a new PASSBOOK in lieu of
the lost one;

6. That I am executing this affidavit to attest to the foregoing facts and for any legal purpose it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________, 2016 in

_________________, Philippines.

__________________
Affiant

SUBCRIBED AND SWORN TO before me

this _______________ in ______________________, Philippines, affiant exhibiting to me his
valid proof of identification.

_________________
Notary Public

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20__