Republic of the Philippines)

City of Tacloban ) s.s.

Province of Leyte )
x-------------------------------x

AFFIDAVIT OF LOSS

I, JAHZIEL L. DUALLO, of legal age, single, Filipino and a resident of

Brgy. 94, Mahalika St. Tigbao, Tacloban City, after having been duly sworn to in
accordance with law do hereby depose and say;

1. That I am a holder of City Savings Bank (CSB) ATM Card with business
address located at Salazar St., Tacloban City;

2. That above-mentioned ATM card was kept in my possession and was

placed in my shoulder bag together with some of my other important
documents;

3. That above-mentioned ATM card was kept in my possession and was

placed in my wallet together with some of my other important documents;

4. That yesterday at 10:00 o’clock in the morning more or less while I was
in the downtown of Tacloban City my wallet was lost without my knowledge and
believed to have been pickpocketed by an unknown person;

5. That I have made diligent efforts to locate above-mentioned ATM and

but the same have proven futile, hence, for all intent and legal purposes I
considered it lost and beyond recovery;

6. That in view thereof, I am now requesting the of City Saving Bank

(CSB), Salazar St., Tacloban Branch, to issue another ATM card in lieu of the lost
one;

7. That I hereby hold the City Savings Bank (CSB), Salazar St., Tacloban
City Branch, free and harmless from any loss or damage that it may incur by
reason of or in connection with the issuance of a new ATM card;

IN WITNESS WHEREOF, I have hereunto affix my signature this 18 th day

of March 2016 at Tacloban City.

JAHZIEL L. DUALLO
Affiant

SUBSCRIBED AND SWORN to before me this 18th day of March 2016 at

Tacloban City. Affiant exhibited to me her PRC (Professional Teacher) ID with
No. 1171893 valid until October 10, 2016.

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