I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of _______________________________, after having been duly sworn to in accordance with law, depose and state THAT:
1. I maintain a Savings Account with S/A No. _____________ with _____________ Bank with a credit balance of _____________ (P_____________);
2. Sometime on ____________, the passbook of the above-mentioned account was lost in the following manner:
3. Despite diligent efforts exerted, I could no longer locate, find or recover the said passbook , and to the best of my knowledge, the same is truly lost;
4. In view thereof, I now desire and hereby request ______ Bank to issue another passbook in lieu of the lost one and I am willing to surrender the lost passbook in the event that the same could be found;
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 passbook in lieu of the one which was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati City, Metro Manila , Philippines .