Republic of the Philippines )

Province of Oriental Mindoro )S.S.

Municipality of Gloria )
x----------x

AFFIDAVIT OF LOSS

I, EPITACIA S. SEMILLA, married, Filipino, of legal age, and a resident of Brgy. Kawit,
Gloria, Oriental Mindoro, Philippines, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I am a depositor of Rural Bank of Pola, Gloria Branch, located at Maligaya, Gloria,
Oriental Mindoro, Philippines with savings account number 303, with account name
EPITACIA SEMILLA AND/OR GOMEZ SEMILLA;

2. That last November 14, 2011, I discovered that my PASSBOOK was not on the cabinet
where I usually kept my personal files and documents.

3. That the said passbook contains an amount of more or less THREE THOUSAND SIX
HUNDRED NINETY-SIX PESOS AND 73/100 (Php3,696.73)

4. That despite diligent search and efforts to locate the said Rural Bank of Pola Passbook, I
could not find it, such that I now believe that it was now lost beyond recovery.

5. That my Rural Bank of Pola Savings Passbook has not been confiscated by the bank or
used as a collateral in any loan.

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of a replacement Savings Passbook, in lieu of the
one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of November, 2011 at
Gloria, Oriental Mindoro, Philippines.

____________________________
EPITACIA SEMILA
AFFIANT

SUBSCRIBED AND SWORN to before me this 16 th day of November, 2011

at Gloria, , Oriental Mindoro, affiant personally known to me and exhibiting to
me her Competent Evidence of Identity a SENIOR CITIZEN ID with number
001291 issued by Office of the Senior Citizen.

ATTY. VIC RUSKIN M. ONG

Doc. No. 175; NOTARY PUBLIC for Oriental Mindoro
Until December 31, 2011
Page No. 36;
#158, VT Bldg, Gloria, Oriental Mindoro
Book No. II; Roll of Attorney No. 58374
Series of 2011 IBP LRN No. 09628 / Or. Mdo. / 01-27-11
PTR No. 3627123 / Or. Mdo. /01-26-11