Republic of the Philippines)
Province of ____________________) S.S.
City/Municipality of _____________)
x – – – – – – – – – – – – – – x
AFFIDAVIT OF LOSS
I, _____________, Filipino, of legal age, (single / married / widow), and with residence at _____________, Philippines, after being duly sworn to in accordance with law, hereby depose and state:
That I maintain a Savings Account with S/A No. _____________ with _____________ Bank with a credit balance of _____________ (P_____________);
That on or about _____________, the Passbook/Certificate of the above-mentioned account, which has always been in my possession, was lost and its whereabouts cannot be ascertained despite due and diligent search made and undertaken such that I now believe that the same is lost beyond recovery;
That I now request the _____________ Bank to issue a new Passbook/Certificate in lieu of the lost one and I bind myself to surrender the lost Passbook/Certificate in the event that the same is found and/or located;
That I bind myself to indemnify _____________ Bank for any loss and damage it may incur by reason of its issuance or replacement Passbook/Certificate;
That each and every fact herein stated is true and I am willing to testify before any court of justice to substantiate the truth of each and all the said facts.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.