REPUBLIC OF THE PHILIPPINES)

PROVINCE OF TARLAC ) S.S.

TARLAC CITY…………………… )

AFFIDAVIT OF LOSS

I, NINO NIKO T. GOMEZ, of legal age, single, Filipino citizen, and a

resident of Barangay Maligaya, San Miguel, Tarlac, after having duly sworn to in
accordance with law, hereby depose and state - That:
1. I am a holder of a BDO issued ATM/Debit card provided by International
Wiring System (IWS) for issuance of monthly salary;
2. That on May 2020, the above described ATM/Debit card went missing and
got lost when I went to withdraw my cash funds from the said bank;
3. That despite diligent efforts exerted to locate, the same could no longer be
found and is now deemed lost and beyond recovery.
4. That I am executing this affidavit to inform the proper authorities concerned
about the loss of said ATM/Debit card for possible replacement in lieu of the
lost and for whatever legal intents and purposes it may serve.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this
_________________ at Tarlac City, Philippines.

NINO NIKO T. GOMEZ

Affiant

SUBSCRIBED AND SWORN to before me this, __________________ at

Tarlac City, Philippines.

Doc. No. _________;

Page No._________;
Book No._________;
Series of 2020.