Republic of the Philippines )

Tacloban City ) s.s.

AFFIDAVIT

I, , Filipino citizen, of legal age, widower, with residence at

Magbangon, Cabucgayan, Biliran, after having been duly sworn to in accordance
with law, hereby depose and state:

1. That on July 14, 2014, at around 5:30A.M., I discovered that my

Unionbank ATM / Debit card with card number 9570-2158-1201-9 have
been missing and stolen from my residence at Lot 2 Blk. 1 corner Montilla-
Masbate, Kassel City, Abucay, Tacloban City.

2. That on the very same day of discovery, at around 7:00 A.M., I

immediately reported to and filed a complaint at the Barangay Hall Brgy.
Abucay, Tacloban City;

3. That despite diligent effort to locate the same, I could not find the same,
such that I now believe they are already lost beyond recovery;

4. That said items were not confiscated by authorities or used in violation of

the law;

5. That I am executing this affidavit to attest to the truth and veracity of the
foregoing facts and for whatever legal purposes the same shall serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day

of July 2014 in Tacloban City, Leyte, Philippines.

_______________
Affiant

SUBSCRIBED and SWORN to before me this ____ day of July 2014 in

Tacloban City, Leyte, Philippines.

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