REPUBLIC OF THE PHILIPPINES)

CITY OF MANDAUE ) s. s.

AFFIDAVIT

I, MERLIZA REYES AGUE, of legal age, Filipino, single and a

resident of Unit 2, Cabrera St., Casuntingan, Mandaue City, after
having been sworn to in accordance with law, hereby depose and say:

1. That I am the owner of a Philippine National Bank (PNB)

passbook with Account No. 300210011774;

2. That the said passbook was stolen last July 2, 2018 at around
three o’clock in the morning;

3. That I am executing this affidavit for the issuance of a new

passbook in lieu of the stolen one under the same account
number and to attest to the existence and truthfulness of the
foregoing facts;

4. Affiant further sayeth naught.

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

day of July 2018 at Mandaue City, Philippines.

MERLIZA REYES AGUE

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of July

2018 at Mandaue City, Philippines. Affiant exhibited to me her Unified
Multi-purpose I.D. CRN -0111-3468387-1.

Doc. No. ______;

Page No. _____;
Book No.______;
Series of 2018.