REPUBLIC OF THE PHILIPPINES)

QUEZON CITY )S.S.

AFFIDAVIT OF LOSS

I, _______________, of legal age, with address at

____________________________________________________________,
after having been duly sworn to in accordance with law hereby depose and
states, that:

1. I am an account holder of ______________________________;

2. As such I was issued an Automated Teller Machine Card (A.T.M.);

3. I used to keep the said ATM Card in my wallet. However, on _________

my wallet, where my said ATM Card and other important papers that are being
kept, are nowhere to be found;

4. I exerted diligent effort to locate the same, but said effort prove fruitless
to date;

5. I am executing this affidavit to attest to the truth of the foregoing facts

and for whatever legal purposes it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

_________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _______at

Quezon City.

Doc. N0. ___;

Page N0.___;
Book N0. _ ;
Series of: ____.