Republic of the Philippines )

Province of Davao del Norte) Sc.

City of Tagum )
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AFFIDAVIT OF LOSS

I, SHIRLEY T. SALANTES, of legal age, Filipino, single and a resident

of Purok 1, Kilagding, Laak, Compostela Valley Province, Philippines, after
having been duly sworn to in accordance with law, do hereby depose and say
that:

I am a bona fide holder of a Disclosure Statement for a Household

Loan with City Savings Bank (CSB) in Tagum City;

Sometime in the month of May 2018, the above-described Disclosure

Statement was misplaced and lost from my possession;

Despite diligent search and efforts, the same could no longer be found
such that I believe that it is now lost beyond recovery;

I execute this affidavit to attest to the truth of the foregoing facts and
to inform the proper authorities concerned regarding such loss.

IN WITNESS WHEREOF, I hereunto affix my signature this 30th day

of October 2019 at Tagum City, Davao del Norte, Philippines.

SHIRLEY T. SALANTES
Affiant

SUBSCRIBED AND SWORN to before me this 30th day of October

2019 at Tagum City, Davao del Norte, Philippines. Affiant exhibited to me her
Professional Regulations Commission identification card bearing no. 0765808
issued in Davao City, Philippines.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.