REPUBLIC OF THE PHILIPPINES )

CITY OF MALABON )S. S.

AFFIDAVIT OF LOSS

I, ZENAIDA S. MACABENTA, 70 yrs. old, presently residing at No. 10

Sta. Cruz St., Hulong Duhat, Malabon City, after having been duly sworn to in
accordance with law, deposes and states the following:

1. That I am a holder of Pass Book issued by Philippine Business

Savings Bank;

2. That sometime on the 5th day of June 2016, I noticed that the
envelope where my Pass Book was enclosed was lost;

3. That diligent efforts were exerted to look for the said envelope as
well as my Pass Book but such efforts proved futile;

4. That the Pass Book issued by Philippine Business Savings Bank is

already lost and can no longer be recovered;

5. That I am executing this affidavit to attest the veracity of the

foregoing statements of fact for whatever legal, and other intents
this affidavit may duly serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this 10th day of June
2016, in the City of Malabon, Philippines

ZENAIDA S. MACABENTA
Affiant

SUBSCRIBED AND SWORN TO before me on this 10th day of June 2016. Affiant
exhibiting to me her Senior Citizen ID with Control No. 003052.

ATTY. HAROLD KIM C. HERNANDO

Public Attorney II
PAO – MALABON DISTRICT OFFICE
Pursuant to R.A. 9406
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