REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
x-----------------------x

AFFIDAVIT OF LOSS

I, ROSALYN DATOR BAD-E, Filipino, of legal age, married and a resident of Purok 7,
San Salvador, Prosperidad, Agusan del Sur, after being duly sworn to in accordance with law,
hereby depose and state:

1) That I am the same person executing this Affidavit;

2) That I am a depositor/account holder of Philippine National Bank (PNB), located at San

Francisco, Agusan del Sur;

3) That being a depositor of PNB, I was issued with a depositor's AUTOMATIC

TELLER'S MACHINE Card with Account Number 402610079919 for all my
withdrawal transaction with the bank;

4) That I used to keep the above ATM card inside my handbag, which I carry with me
wherever I go;

5) That it was only recently that I searched for the said ATM card but I could no longer find
the same;

6) That despite diligent search and efforts to locate the ATM card, the same could not be
found such that I now consider it lost beyond recovery; and

7) As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing, for
the re-issuance of such ATM card and for any legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th day of August 2019 at
Poblacion, Prosperidad, Agusan del Sur.

ROSALYN DATOR BAD-E

Affiant

SUBSCRIBED AND SWORN to before me this 25th day of August 2019 at Poblacion,
Prosperidad, Agusan del Sur.

Doc.  No. :  212

Page  No. :  43
Book No. :  VI
Series of 2019