Republic of the Philippines )

City of Legazpi ) S.s

AFFIDAVIT OF LOSS

I, (name) of legal age, Filipino citizen and a resident of (address) under oath do
hereby deposes and says that:

1. I am a holder of an (id card) issued by (institution);

2. Sometime on or about (date), while I was (reason), I discovered that my wallet
is missing from the backpack where I placed the same;
3. Despite diligent search and efforts to locate the same, it proved futile;
4. Said (id card) was not confiscated by the authorities of the bank by reason of
any violation;
5. I am executing this affidavit to attest to the truth of the foregoing facts and to
request for a replacement of said (id card).

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereby affix my signature this 3rd day of July 2019 in
Legazpi City, Philippines.

(name)

SUBSCRIBED AND SWORN before me this 3rd day of July 2019 affiant
personally appeared and exhibited to me proper and sufficient document of her
identification.

NOTARY PUBLIC