REPUBLIC OF THE PHILIPPINES )

CITY OF TAGBILARAN ) S.S.

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AFFIDAVIT OF LOSS

I, SARAH PALOMARES DUMARAN, of legal age, married, a Barangay Taytay, Loon,

Bohol, after having been duly sworn in accordance with law hereby depose and state that:

1. I am the owner of a First Consolidated Bank (FCB) PITAKArd attached to Account

Number 0221001005634;

2. Sometime last September 1, 2019, I was on my way to withdraw from the said account
when I realized that my small purse, containing my PITAKArd, was lost and misplaced
from my bag;

3. I had gone through all my things and had searched all over my house, however, despite
my utmost diligent effort and meticulous endeavor, I was unable to recover the said purse
containing the said PITAKArd;

4. I am executing this affidavit to attest to the truthfulness of the foregoing and for whatever
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this 3rd day of September
2019, at Tagbilaran City.

SARAH PALOMARES DUMARAN

Affiant
SSS. ID No. 06-2256048-1

SUBSCRIBED and SWORN to before me this 3rd day of September 2019, at Tagbilaran City. I
hereby certify that I have personally examined the above-named affiant and that I am satisfied that
the foregoing statements were given by him voluntarily and of his own free will.

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