Republic of the Philippines)

Province of Iloilo ) S.S.

x-----------------------x

Affidavit of Loss
I, _____________________, Filipino, of legal age, single and with residence address at
_______________________, Philippines, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I am a holder of Professional Driver’s License, PRC issued ID, Land Bank of the
Philippines ATM Card and two (2) BPI ATM Cards issued under my name;

2. That last _______, when I was doing an errand at _____________, Iloilo, I discovered that
my color orange wallet placed inside my bag was no longer found there;

3. That despite diligent search and efforts to locate the said wallet containing abovementioned
identification Cards and ATM Cards in the premises where I might probably lost it, I could
not find the same such that I now have reasons to believe that the said wallet is now lost and
can no longer be recover; and

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of new Professional Driver’s License, PRC Card,
Land Bank of the Philippines ATM Card and BPI ATM Cards before the Government
Agencies or Institutions and Private Institutions appropriate, in lieu of those that were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________________.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for Province of
Iloilo this ____________________. Affiant personally came and appeared with
________________________ known to me as the same person who personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the contents of said
instrument.

Doc. No.________.
Page No. _______.
Book No. _______.
Series of 2020.