Republic of the Philippines )

Province of Pangasinan )
City of Dagupan ) S.S.

AFFIDAVIT OF LOSS
(A.T.M. Card)

I, (AFFIANT’S NAME), of legal age, Filipino, married to (NAME OF AFFIANT’S

SPOUSE, if any), and resident of (AFFIANT’S ADDRESS), after having been sworn in
accordance with law hereby deposes and states that:

1. I am the true and lawful owner of an Automated Teller Machine (A.T.M.) Card No. (
) issued by the (NAME OF BANK) of (NAME OF THE PLACE OF THE BANK’S
BRANCH) on (DATE OF ISSUE);

2. sometime on (DATE), I was looking for the said A.T.M. Card, but to my surprise, the
same could not be found (ADD, CHANGE OR MODIFY BY INSERTING THE
DETAILS NEEDED ACCORDING TO THE CIRCUMSTANCES);

3. despite earnest and painful efforts on my part to search, locate and retrieve the
aforesaid A.T.M. Card, the same proved me futile and in vain;

4. said A.T.M. Card was not confiscated by any officer of the law or the officers of
(NAME OF BANK) by reason of any violation of any law, ordinance, presidential
decree or rules and regulations of the said bank; neither was it offered as collateral for
any loan nor transferred to any person or entity nor used for any unlawful purpose;
and

5. I am executing this affidavit to attest to the truth of the foregoing facts, to request
from the (NAME OF BANK) of (NAME OF THE PLACE OF THE BANK’S
BRANCH) a replacement copy of the said A.T.M. Card, and for all legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day of

_______________, 20___ in the City of Dagupan, Province of Pangasinan, Philippines.

_________________________________
(AFFIANT’S NAME)
Affiant