Republic of the Philippines)

Province of Negros Oriental)

City of Dumaguete…………) S.S

AFFIDAVIT OF LOSS

I, _______________________________, Filipino, of legal age, and a resident of

Capalasanan, Lazi, Siquijor, after having duly sworn in accordance with law, do hereby
depose and state that:

1. I am the holder of the ATM Card with Account No. ____ duly issued by CITY
SAVINGS BANK;

2. Recently, I discovered that said ATM Card was probably lost or misplaced;

3. Despite diligent search and efforts to locate the said ATM Card, I could not find the
same such that I now believe that it is now lost beyond recovery;

4. As such that I am executing this affidavit of loss to attest to the truth of the foregoing
and to support the application for the issuance of new one in lieu of the one which was
lost.

5. Further, I execute this affidavit for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed our hands this August 18,
2023, at Dumaguete City, Philippines.

_______________________
Affiant

SUBSCRIBE AND SWORN TO before me this August 18, 2023 at Dumaguete

City, Philippines, with affiant exhibiting his ___________.