REPUBLIC OF THE PHILIPPINES )

CITY
OF
________
)SS.
X-----------------------------------------X
AFFIDAVIT OF LOSS

I, (insert name here), Filipino, of legal age, single and a resident of

(insert address here), Philippines, after having duly sworn to in accordance
with law, hereby depose and say that:

1.
I am the holder of an Automated Teller Machine card
number (insert number here) under Account No. ____________
issued by (insert name of bank here);
2.
The credit balance of this
______________ as of _______ , 2006;

account

is

Php

3.
I lost said ATM on (insert date here) and that I
exerted all efforts to locate the same but I could not remember
exactly where I placed/left it and it is considered lost for all
legal purposes;
4.
The money represented by the balance to the credit
of the account is my personal property and that I have no
assignment, transfer or pledge thereof
5.
Said ATM Card was not confiscated by any officer of
the law or the officers of (name of bank) by reason of any
violation of any law, ordinance, presidential decree or rules and
regulation of said bank; and neither was it offered as collateral
for any loan;
6.
I am executing this affidavit to attest to the
foregoing facts and for the purpose of securing the issuance to
me of a replacement ATM card in lieu of the one that was lost;
7.
That I hereby agree to hold the (name of bank) its
officers and employees, free and harmless and to indemnify

it/them for any loss that it/they may sustain by issuing another
ATM Card;

IN WITNESS WHEREOF, I have hereunto set

______________ in the City of ___________, Philippines.

my

hand

this

_______________
Affiant
SUBSCRIBED AND SWORN to before me this _______________ in the
City of ____________ Philippines, affiant having exhibited to me (his or her)
community tax certificate with no. _______________ issued on
______________ at _____________.
Doc. No.____;
Page No.____;
Book No.____;
Series of 2006.