REPUBLIC OF THE PHILIPPINES)

CITY) S.S

AFFIDAVIT OF LOSS

I, ALILIAN MARTINEZ, of legal age, single, Filipino, and presently

residing at __________________________________________________ after having
been sworn to in accordance with law hereby depose and state:

1. That I am a holder of an _______________ ATM with number

__________________;

2. Sometime in ______________, I noticed my ATM Card was missing and

assumed it was misplaced nowhere to be found;

3. That despite diligent searches and efforts made/undertaken to

locate said wallet were proven futile and I believe the said wallet is
lost beyond recovery;

4. That I am executing this affidavit to attest to the facts mentioned

above and as a requirement for its replacement.

FURTHER AFFIANT SAYETH NAUGHT.

ALILIAN MARTINEZ,
Affiant

SUBSCRIBED AND SWORN to before me this _____day of

__________________,in________________, Philippines, affiant exhibited to me her
_________________________________________ issued at_________________.

Doc. No. ____

Page No. ____
Book No. ____
Series of 201_.