Republic of the Philippines)

City of Bislig ) s.s

x----------------------------------x

AFFIDAVIT OF LOSS

I, JOSE Q. CANDIA, JR., of legal age, single, Filipino citizen, residing at Purok 4-A,
Castillo Village, Mangagoy, Bislig City, Surigao del Sur, after being duly sworn in accordance
to law, depose and state THAT:

1. I am a bona fide holder of an ATM card duly issued by City Savings Mangagoy
Branch;

2. Sometime on the first week of January 2020, I have discovered that the said ATM
card was missing;

3. Despite diligent efforts, I could not find nor locate the same and I believe that it is
truly lost;

4. I am executing this affidavit for whatever legal purpose it may serve and to
request for replacement of said ATM card;

5. I attest to the truth of the foregoing information.

IN TESTIMONY WHEREOF, I have here unto affixed my signature this _____ day
of _______________, 2020 at ________________________, Bislig City, Surigao del Sur.

JOSE Q. CANDIA, JR.

Affiant
I.D No.__________________

SUBSCRIBED AND SWORN to before me this _____ day of

_____________________at Bislig City, Surigao del Sur, affiant exhibiting to me his
Identification Card No.____________________, issued on _________________________at
____________________, Bislig City, Surigao del Sur.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2020