Republic of the Philippines) SS

City of _____ . . . . . . . . .)

AFFIDAVIT OF LOSS

I, (name), of legal age, married, Filipino, and a resident of ________,

Philippines, after having been sworn to under oath hereby state, that:

1. I was issued an ATM Card by (bank) - _______ Branch with an

Account No. __________;

2. However, sometime last November 2019, while I was in ______ and

about to make a withdrawal, I noticed that my said ATM Card was
missing as it was no longer with me or in my wallet and I realized that
I may have misplaced it after I made my last withdrawal of money,
however, I exerted efforts to locate the same by looking for it but my
efforts proved futile and as such, I considered said ATM Card lost
beyond recovery;

3. Said ATM Card was neither confiscated by the authorities nor was it
used for unlawful purpose;

4. This Affidavit is hereby executed to attest to the truthfulness of the

foregoing and for all legal intents and purposes it may serve.

Signed this __th day of ____20__, _____City, Philippines.

_______________
Affiant
______ID Card No. ___________

BEFORE ME, a Notary Public for and in the City of ______, personally
appeared the affiant known to me and to me known to be the same person who
executed the foregoing.

WITNESS MY HAND AND SEAL this __th of _____ 20__ at _______

City, Philippines.