Republic of the Philippines }

City of Bacolod } S.c.

x------------------------------------x
AFFIDAVIT OF LOSS
I, JOSEFINA S. YAP, of legal age, married, ilipino and a resident of !"#$ %a&aan
Road 'illa (ngela Subd., 'illamonte, Bacolod City, Philippines, after ha)ing been duly
s&orn in accordance &ith la&, do hereby depose and say that*
I am the depositor of a +ollar Sa)ings (ccount passboo, &ith account no.
!$-."$$/0/$- in B+1 2ast Branch.
3hen I &as about to deposit sometime in the first &ee, of 4ay /$!", I noticed that
my passboo, is missing. I immediately notified the ban, of my loss.
+espite my diligent efforts to locate the abo)e-mentioned passboo, for the last
couple of days no&, I am unable to locate the same.
I execute this affida)it for the purpose of attesting to the truth of the foregoing facts
and for &hate)er legal purpose it may ser)e best.
I further sayeth none.
JOSEFINA S. YAP
Affiant
S5BSCRIB2+ (6+ S31R6 71 B21R2 42 this 8888 day of 4ay, /$!" at the
City of Bacolod, the affiant exhibiting to me her Community 7ax Certificate 6o. 9
:o)ernment Issued I+ 8888888888888888888 issued at 8888888888888888 on
8888888888888888.
+oc. 6o. 88888
Page 6o. 8888
Boo, 6o.88888
Series of /$!".