REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

AFFIDAVIT OF LOSS

I, _______________________________________, of legal age, and a

resident of ___________________________________, after having been duly sworn to
in accordance with law, hereby depose and state that:

1. I am the owner of an ATM Card issued by Unionbank with Account No. for
payroll purposes;

2. The said ATM Card was usually placed inside my bag;

3. However, last April 16, 2018, upon reaching my house I found out that the said
ATM Card was no longer found inside the bag;

4. Diligent efforts were exerted to find the said ATM Card but to no avail, hence,
the ATM is considered lost for all intents and purposes; and

5. I execute this affidavit to attest to the veracity of the foregoing statements,

and to report the loss of the said item so I can be cleared from resignation
requirements of my former company, _____________________ and for
whatever legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of July
2019 at City of Manila, Philippines.

_________________________________
Affiant
Passport ID No.
Valid until September 28, 2020
Issued by: Department of Foreign Affairs

SUBSCRIBED AND SWORN TO before me this ____ day of July 2019 at City of
Manila, Philippines, affiant sufficiently proved his identity by exhibiting to me the above
identification, as his competent evidence of identity under the 2004 RULES OF NOTARIAL
PRACTICE.

Doc No. _______

Page No. ______
Book No.______
Series of 2019.