REPUBLIC OF THE PHILIPPINES )
CITY OF MAKATI ) S.S.
x----------------------------x
AFFIDAVIT OF LOSS
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:
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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.
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 Manila, Philippines .
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Affiant
SSS ID No. _____________
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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.