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REPUBLIC OF THE PHILIPPINES )

MEYCAUAYAN CITY BULACAN ) S.S.

AFFIDAVIT OF LOSS

I, ____________________, Filipino, of legal age, and a resident of


______________________________________, after being duly sworn to in accordance
with law, hereby depose and state that:

1. I am a holder of an ATM Card issued by the Philippine National


Bank, the account number of which I cannot remember;

2. The said account is where my pension is deposited;

3. On _________________, I lost my ATM Card somewhere in the


province of Ilocos Sur;

4. Despite diligent search and efforts exerted to locate the said ATM
Card, I could not find it, such that I now believe that it is now lost and beyond
recovery;

5. Said card is not offered as collateral for any loan;

6. As such, I am executing this Affidavit of Loss to attest to the truth


of the foregoing and to support my application for the issuance of a new ATM
Card, in lieu of the one that I lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _______day of


______________ at _____________________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ________________________,


affiant satisfactorily proven to me his identity through his
_________________________ and, that he is the same person who personally
signed before me the foregoing affidavit and acknowledged that he executed the
same.

Doc No. ____;


Page No. ___;
Book No. __;
Series of _____.