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REPUBLIC OF THE PHILIPPINES)

TARLAC CITY) S.S.

I, DENNIS TACUSALME GARIDAN, resident of and with postal


address at BLK 4, Tarvet, San Rafael, Tarlac City after having been duly
sworn to in accordance with law do hereby depose and say:

That I was issued and is a true and lawful owner of a


certain Banco De Oro (BDO) SM Tarlac Branch, Kabayan
Savings Account Number

That sometime in of this year, I placed my passbook in


my drawer in my office and when I was about to retrieve the
same, the said passbook could not be found;

That I tried to locate it in all places possible with utmost


efforts and diligence, but the same could not anymore be
located, and is now considered lost;

That I am executing this affidavit to attest to the truth of


the foregoing and to request from the {Bank name and branch},
to cancel the old one and issue to me a new passbook under
the same Savings Account Number. } - reasons

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


_______________. 20___ at _________________________.

{name of person}
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of


______________, 20___ in _____________ City, with affiant exhibiting his
CTC No. ______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC
Until December 31,
20___

Doc. No. : ________;


Page No. : ________;
Book No. : ________;
Series of 20___.