Affidavit of Loss Passbook) Republic of the Philippines) Province of ____________________) S.S.

City/Municipality of _____________) x--------------x AFFIDAVIT OF LOSS I, _____________, Filipino, of legal age, (single / married / widow), and with residence at _____________, Philippines, after being duly sworn to in accordance with law, hereby depose and state: That I maintain a Savings Account with S/A No. _____________ with _____________ Bank with a credit balance of _____________ (P_____________); That on or about _____________, the Passbook/Certificate of the above-mentioned account, which has always been in my possession, was lost and its whereabouts cannot be ascertained despite due and diligent search made and undertaken such that I now believe that the same is lost beyond recovery; That I now request the _____________ Bank to issue a new Passbook/Certificate in lieu of the lost one and I bind myself to surrender the lost Passbook/Certificate in the event that the same is found and/or located; That I bind myself to indemnify _____________ Bank for any loss and damage it may incur by reason of its issuance or replacement Passbook/Certificate; That each and every fact herein stated is true and I am willing to testify before any court of justice to substantiate the truth of each and all the said facts. IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines. Affiant (JURAT)