Sample Affidavit of Loss of Passbook

CITY OF MAKATI            ) S.S.


 I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of _______________________________, after having been duly sworn to in accordance with law, depose and state THAT:

1. I maintain a Savings Account with S/A No. _____________ with _____________ Bank with a credit balance of _____________ (P_____________);

2. Sometime on ____________, the passbook of the above-mentioned account was lost in the following manner:

3. 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;

4. In view thereof, I now desire and hereby request ______ 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;

5. 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 ___________________ in Makati City, Metro ManilaPhilippines.

SSS ID No. _____________

        SUBCRIBED AND SWORN TO before me this ___________________ in _________________Philippines, affiant exhibiting to me his/her competent evidence of identity by way of __________________ issued at ______________ on __________________.

Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2013.