Republic of the Philippines )

Province of Sorsogon
) S.S.
Municipality of Bulan
)
AFFIDAVIT OF LOSS
I, ALEX D. GILLEGO, of legal age, Filipino, married and a resident of
Purok 4, San Vicente, Bulan, Sorsogon, after being duly sworn according to
law, do hereby depose and state:
1. That I am a bonafide depositor of Rural Bank of San Jacinto, Bulan
Branch, Bulan, Sorsogon and by virtue of which a Savings Passbook
was issued to me;
2. That sometime on December 2016, I could no longer locate the said
Passbook among my belongings at my residence;
3. That despite my diligent efforts to locate the same, it proved futile
thus I am considering said Passbook lost forever;
4. That I have freely executed this affidavit to attest to the foregoing
facts and for the purpose of reissuance in lieu of the lost one.
IN WITNESS WHEREOF, we have hereunto set our hand this 5th day of
January 2017 at Bulan, Sorsogon, Philippines.
ALEX D. GILLEGO
Affiant
SUBSCRIBED AND SWORN TO before me, this 5th day of January 2017
at Bulan, Sorsogon, Philippines, by affiant who exhibited to me his Drivers
License ID with No. E05-08-000419.
Doc. No._____;
Page No._____;
Book No._____;
Series of 2017.

MOISELLE G. MAGDAMIT
Notary Public
Until December 31, 2018
T. De Castro St., Zone 8, Bulan, Sorsogon
MCLE: in compliance under the New
Compliance Period
PTR No. 0473423 Bulan, Sorsogon 01/03/17

IBP No. 1061151 Pasig City 01/05/17

Roll No. 64812