REPUBLIC OF THE PHILIPPINES )
PROVINCE OF LAGUNA ) S.S
MUNICIPALITY OF LOS BANOS )
AFFIDAVIT OF LOSS
I, DORILA D. CARIÑO, married, of legal age, Filipino, residing at
3066 San Isidro Village, Anos, Los Baños, Laguna, after having been duly
sworn to in accordance with law, do hereby depose and state, that:
1. I am a depositor of under with Account Number and as such I was
issued a passbook and/or ATM card.
2. I used to keep my said passbook and/or ATM card in my
table/drawer at my office at ERDB, Forestry Campus, University of
the Philippines, Los Banos, Laguna. Just recently, I discovered that
my said passbook and/or ATM card was missing. Thinking that it
could have been misplaced, I tried to locate it; but despite diligent
efforts, I could not locate it; hence I have considered the same to
have been lost and beyond recovery.
3. I have executed the foregoing to attest the truth of the above
averments; and to inform the said bank of such lost and for
issuance of the a new savings passbook and/or ATM card in lieu of
the lost one, and for all legal intents and purposes.
IN WITNESS WHEREOF, I have hereunto affixed my signature
this ____________, in the Municipality of Los Baños, Province of Laguna,
Philippines.
DORILA D. CARIÑO
Affiant
SUBSCRIBED AND SWORN TO before me this ______________ in the
Municipality of Los Baños, affiant exhibiting to me his competent evidence of
identity by way of: (ID Details).
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2024.
