Republic of the Philippines )

Province of Oriental Mindoro )S.S.

Municipality of Gloria )

x----------x

AFFIDAVIT OF LOSS
I, FORTUNA F. JABAL, Filipino, of legal age, married, and a resident of
Maligaya, Gloria, Oriental Mindoro, Philippines, after being sworn in
accordance with law, depose and state:

1. That I have an ATM ACCOUNT in the Philippine National Bank

(PNB) located in Pinamalayan, Oriental Mindoro.

2. That on February 2, 2012, my wallet which contains my ATM

CARD was lost.

3. That the said ATM CARD contains more or less three thousand
pesos (Php 3,000.00).

4. That despite diligent search and efforts to locate my wallet together

with my ATM CARD, I could not find it such that I now believe that
it is now lost beyond recovery.

5. That my ATM CARD has not been confiscated by the bank or used as collateral in
any loan.

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

of the foregoing and support my application for the issuance of a
new ATM CARD, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ in

Gloria Oriental Mindoro, Philippines.

FORTUNA F. JABAL
AFFIANT

SUBSCRIBED AND SWORN to before me this ___________ at Gloria,

Oriental Mindoro, affiants personally known to me and exhibiting to me her
Competent Evidence of Identity a Senior’s ID with number 2166512, Issued by
the Republic of the Philippines Office of Senior Citizen’s Affair on February 20,
1996.

Doc. No. ____;

Page No. ____;
Book No. I;
Series of 2012