Republic of the Philippines)

Province of Quirino)
Municipality of Diffun)s.s.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, IMELDA D. GEPILANO married to LOUIE B. GEPILANO both

legal age, Filipino, and both resident of Andres Bonifacio, Diffun,
Quirino, after having been sworn in accordance with law, hereby
deposes and states the following:

1. That we are owner of a PASSBOOK of VETERANS BANK with an

account no. 0056-539-633-100;

2. That sometime this February 2019 I noticed that the said

PASSBOOK was missing;

3. That to my knowledge, the said PASSBOOK was lost;

4. That I took great pains to look for the said PASSBOOK but no avail;

5. As such, I am executing this affidavit to attest to the foregoing facts

and to support the application for the issuance of a new in lieu of the
one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 21th day of

February 2019 at Diffun, Quirino, Philippines.

IMELDA D. GEPILANO
Affiant

SUBSCRIBED and SWORN TO before me on the date and at the

place indicated below. The affiant exhibited to me his competent evidence of
identity as indicated above.

Signed this 21th day of February 2019 at Diffun, Quirino.

WITNESS MY HAND AND SEAL.