REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
x-----------------------x

AFFIDAVIT OF LOSS

I, NENITA P. PALANOG , Filipino, of legal age, and a resident of Purok 13, Poblacion,
Prosperidad, Agusan del Sur, after being duly sworn to in accordance with law, hereby depose
and state:

1) That I am the same person executing this Affidavit;

2) That I am a depositor/account holder of Peoples Banks of Caraga (PBC), located at

Poblacion, Prosperidad, Agusan del Sur;

3) That being a depositor of PBC, I was issued with a depositor's SAVINGS PASSBOOK
for all my deposit and withdrawal transaction with the bank;

4) That I used to keep the above passbook inside my handbag, which I carry with me
wherever I go;

5) That it was only recently that I searched for the said PBC Passbook but I could no longer
find the same;

6) That despite diligent search and efforts to locate the PBC Passbook, the same could not
be found such that I now consider it lost beyond recovery; and

7) As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing, for
the re-issuance of such Passbook and for any legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 27th day of August 2017 at
Purok 13, Poblacion, Prosperidad, Agusan del Sur.

NENITA P. PALANOG
Affiant
CTC: CCI2016 11716749

SUBSCRIBED AND SWORN to before me, 27th day of August 2017 at Purok 13,
Poblacion, Prosperidad, Agusan del Sur.

Doc. No. : 370

Page No. : 74
Book No. : III
Series of 2018.