Province of Quirino }

Municipality of Diffun }s.s.

AFFIDAVIT OF LOSS

I, TERESITA T. VILLANUEVA, of legal age, Filipino, married and a resident of

Maria Clara, Diffun, Quirino, after having been duly sworn to in accordance
with law, depose and state THAT:

1. I am a holder of Passbook account issued by Disadeco Bank, Diffun

Branch;

2. I maintain a Savings Account with S/A No. 002544 with Disadeco

Bank with a credit balance of ________________;

3. Sometime on February 2018, the Passbook of the

above-mentioned account was lost in the following manner:
___________________________________________________
___________________________________________________

4. Despite diligent efforts exerted, I could no longer locate, find or

recover the said passbook, and to the best of my knowledge, the
same is truly lost;

5. In view thereof, I now desire and hereby request Disadeco Bank to

issue another passbook in lieu of the lost one and I am willing to
surrender the lost passbook in the event that the same could be
found;

6. As such, I am executing this affidavit to attest to the foregoing facts

and to support the application for the issuance of a new passbook in
lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of

March, 2018 at Diffun, Quirino.

TERESITA T. VILLANUEVA
PRC LICENSE NO. 0510149

SUBCRIBED AND SWORN TO before me this 13h day March, 2018 at

Diffun, Quirino.
 Atty. MA. KAREN A. BALDONADO-GUILLERMO
Notary Public
Until December 31, 2019
Doc. No. ; PTR No. 3218465/ 01-03-2018
Page No. ; Lifetime IBP No. 17396/05-20-2017
Book No. 01; ROLL No. 67812/05-26-2017
Series of 2018. (MCLE Governing Board Order No. s-2008)
Diffun, Quirino