AFFIDAVIT OF LOSS

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

of___________________________________________, after having been duly sworn to in
accordance with law, depose and state:

1. That I am a holder of Automated Teller Machine (ATM) Card No.

_________________________duly issued in my favor by_______________;

2. That I used to put said ATM card in my wallet;

3. That sometime on______________________, when I arrived home

from______________________________, I discovered that my wallet no longer in my
pocket;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request_______________________to issue

another ATM card in lieu of the lost one;

6. That I bind myself to save________ harmless from any loss or damage that it may incur in
connection with the issuance of a new ATM card in lieu of the lost one;

7. That I am executing this affidavit to attest to the foregoing facts and for any legal purpose it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this_____ day of _________ in

____________, Metro Manila, Philippines.

________________________
Affiant
 SUBCRIBED AND SWORN TO before me__________
of___________ in________________,Metro Manila, Philippines, affiant exhibiting to me his
valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.