SAMPLE FORM OF AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES )

MAKATI CITY ) SS.

AFFIDAVIT OF LOSS

I, JUAN Z. REYES, of legal age, and with address at XXXXXXXXXX, under

oath, state:

1. THAT I have a Citibank Mastercard bearing No. 12345 and expiring in

July 2020;

2. THAT on XXXXX at around 5:30 PM I boarded a bus bound for Quezon

City;

3. THAT after I got off at corner EDSA and Quezon Avenue, I discovered
that my wallet containing my aforesaid Citibank Mastercard was
gone;

4. THAT I exerted diligent effort to locate the same but to no avail and
thus I consider my Citibank Mastercard as lost and can no longer be
found;

5. THAT I am executing this Affidavit to attest to the truth of the

foregoing facts and to use the same for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I hereunto affix my signature this XXXXXXX at

Makati City.

JUAN Z. REYES
Affiant

SUBSCRIBED AND SWORN to before me this XXXXXX at Makati City,

Affiant exhibiting to me his competent proof of identity bearing his
picture and signature as described below:

NAME TYPE OF NUMBER DATE AND PLACE OF

ID. ISSUANCE/ EXPIRY
DATE.

JUAN Z. PASSPOR XXXX ISSUED ON XXXX AT

REYES T XXXX AND EXPIRING
ON XXXX.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of ______.