REPUBLIC OF THE PHILIPPINES

City of Manila

AFFIDAVIT OF LOSS

We, _____________ and ______________, both of legal age, Filipino,

married and a residents of Retiro St. in Manila, after having been duly sworn to in

accordance with law, depose and state:

1. That my wife, __________________ and I are depositors of PNB Savings Bank –

Banawe, QC Branch.

2. That we are holders of a TIME DEPOSIT CERTIFICATE under account number

_____________________ at said Bank. .

3. That said TIME DEPOSIT CERTIFICATE were duly issued in our favor by PNB Savings
Bank- Banawe, QC Branch sometime last ____________;

4. That we used to put said passports in the drawer of our house in Las Pinas. But since
we have relocated to Calapan Or. Mindoro in 2014, we have not seen such TIME
DEPOSIT CERTIFICATE ever since.

4. That diligent effort to locate the same proved futile;

5. That in view thereof, we now desire and hereby request PNB Savings Bank- Banawe,
QC Branch, to issue a new TIME DEPOSIT CERTIFICATE for us in lieu of the lost one;

6. That we bind ourselves to save PNB Savings Bank – Banawe, QC

Branch, harmless from any loss or damage that it may incur in connection with the
issuance of a new TIME DEPOSIT CERTIFICATE in lieu of the lost one;

7. That we are executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this ___ day of
May 2018 in Manila, Philippines.

_________________ _____________________________________
Affiant Affiant

SUBCRIBED AND SWORN TO before me this __ day of May

2018, in Manila, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

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