Republic of the Philippines)

City of Manila )S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, single, with postal address at No. after

having been duly sworn in accordance with law, hereby depose and say,
THAT:

1. I am a holder of a Banco de Oro Automated Teller Machine

(ATM) card under account number;

2. I used to put the said ATM card in my wallet. Sometime on

29 January 2018, I discovered that the said ATM card was no
longer in my wallet. Diligent effort was exerted to locate the
same but proved to be futile;

3. I am executing this affidavit to attest to the truth of the

foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this ___ day of __________, 2018, City of Manila.

Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of

________________, 2018, affiant exhibiting to me her competent proof
of identity by way of _________________ issued at __________ on
________________.

NOTARY PUBLIC