Republic of the Philippines)

Province of  Cavite ) S.S.

Municipality of Alfonso ) 

AFFIDAVIT OF LOSS
I, JAMES B. WEBB, Filipino, of legal age, resident of General Trias Cavite,
after being duly sworn to in accordance with law, hereby depose and state:

1. I am in possession of my Automated Teller Machine (ATM) card issued by

United Coconut Planters Bank (UCPB) – Alfonso Branch with account no. 710-
10-00070-6;

2. However, on June 1, 2020 I accidentally dropped said ATM card without my

knowledge;

3. Despite diligent search and efforts to recover the said ATM card, the same can
no longer be located;

4. I am executing this affidavit not for any unlawful purpose but only for the
purpose of application for replacement of the said ATM card.

IN WITNESS WHEREOF, I have hereunto set my hand this 4th day of June, 2020
at Province of Cavite, Philippines.

JAMES B. WEBB
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of June 2020 at Alfonso,
Cavite. Affiant exhibiting to me his Gen. Trias Medicare Hospital ID with no. CS-3751

WITNESS MY HAND AND SEAL.

Doc. No. 77 ;
Page No. 17;
Book No. LXXXI;
Series of 2020.