REPUBLIC OF THE PHILIPPINES

)
CITY OF MALAYBALAY
) S.S

AFFIDAVIT OF LOSS
I, ROSE CLAIRE C. DELFIN, of legal age, Filipino and a resident of
Green Fields Subd., B-6, L-6, Casisang, Malaybalay City, Bukidnon, after
being sworn to and in accordance with law, do hereby depose and state:
1. That, I am the Finance Officer of the D Asian Hills Bank, Inc. (A Rural
Bank) with principal office address at 2F DAHBI Center, Fortich Street,
Malaybalay City, Bukidnon;
2. That, one of my functions is to check the Social Security System (SSS)
contribution received from the clients and remit the same to the SSS
Branch Office;
3. That, sometime in December 2007, the SSS Special Bank Receipt Serial
Numbers 673055 EO and 673056 EO were lost inside my drawer
inside the premises of D Asian Hills Bank, Inc. (A Rural Bank)
Malaybalay Branch;
4. That, diligent effort was exerted to locate the same but proved futile;
5. That, I am executing this affidavit in order to attest to the truth of the
foregoing circumstances and for the purpose of reporting the loss of
the above mentioned Special Bank Receipts for replacement thereof
and for other legal purposes.
IN WITNESS WHEREOF, I have hereunto set my signature this
____________________, in Malaybalay City, Bukidnon, Philippines.

ROSE CLAIRE C. DELFIN

Affiant
SUBSCRIBED AND SWORN to before me this ____________________,
affiant exhibiting to me his valid identification card as sufficient proof of his
identity, known to me as the same person who executed the foregoing
instrument. I hereby certify that I have examined the affiant and I am
satisfied that he understood the contents of his affidavit and has voluntarily
executed the same in his own free will.

Doc. No. ________

Page No. ________
Book No. ________

Series of 2015