REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NEGROS OCCIDENTAL)

MUNICIPALITY OF HINOBA-AN ) S.S.
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AFFIDAVIT OF LOSS

I, LORNA M. NAMACPACAN, Filipino, of legal age, married and resident

of Purok 1, Brgy. Alim, Hinoba-an, Negros Occidental, after having sworn to an
oath do hereby depose and say that:

I am the owner of the DUNGGANON ATM with Account No. 54812029;

The said ATM was lost last December 17, 2021 due to Typhoon Odette;

That after thorough deliberation and recall in finding the said ATM but to
no avail. The said ATM are now beyond recovery.

IN WITNESS WHEREOF, I hereby affixed my signature this ______ of

December, 2022 at ________________________, Negros Occidental.

LORNA M. NAMACPACAN
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of March, 2022

at _____________________, Negros Occidental, Philippines.

________________________
Notary Public