REPUBLIC OF THE PHILIPPINES}

City of Cebu
} S.S
AFFIDAVIT OF LOSS
I, , Filipino, and a resident of Unit 3 Oprra Village Capitol Hills, Cebu City,
Philippines, after having been duly sworn in accordance with law hereby depose and
say that:
1. I am a depositor of City Savings Bank ang as a consequence, a holder of a
passbook.
2. Last January 14, 2016, I lost my purse while eating at the food court of
Gaisano Metro Colon which contains some of personal belongings including
my passbook.
3. Due to the loss of my passbook, I can no longer deposit money in the above
mentioned bank which I usually do every start of the year.
4. In my desire to continue to be a depositor of City Savings Bank and to be
updated with my deposit, there is a need for me to secure a new passbook
5. This affidavit is executed as part of the requirements to secure a new
passbook as well as to attest the truth of the foregoing and for whatever legal
purpose and intent it may serve.
IN WITNESS WHEREOF, I hereby sign this Affidavit this ______________ at
Cebu City, Philippines.

Carmel Joyce C.Dacay

Affiant

SUBSCRIBED AND SWORN to before me this ____________________ at Cebu

City Philippines, Affiant personally appeared and exhibited to me her as competent proof
of her identity. Witness my hand and notarial seal.
Doc. No.
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Book No.
Series of

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