AFFIDAVIT OF LOSS

Republic of the Philippines )

Province of Cagayan )

SUBSCRIBED AND SWORN to before me this 19th day of February , 2020 affiant exhibiting to me his
competent evidence of identity by way of presenting PRC ID No. 90012908 issued at Brgy. Caritan,
Tuguegarao City on December 12, 2018.

Wherefore, I am executing this affidavit to attest to the truth of the foregoing and to request the issuance
of a new ATM card to replace the one that was lost.

I am the owner of ATM Card No. CBNA1970 issued by the Bangko De Oro.

Juan C. De la Cruz
Signature of Affiant over Printed Name

IN WITNESS WHEREOF, I hereunto affix my signature this 19 th February 2020 at Brgy. Dugo,
Camalaniugan, Cagayan Valley, Philippines.

I, Juan C. Del la Cruz, Filipino, single, of legal age, resident of Pattao, Buguey, Cagayan Valley,
Philippines, after having been sworn in accordance with law hereby depose and state that:

Sometime around 5:30PM on February 17, 2020 I lost the above ATM Card under the following
circumstances; I left the office at 5:05 and ride a taxi going home. I stopped for a while at 7 eleven at
around 5:25 to buy food stuff and then I noticed that my ATM card was missing.

The said ATM Card has not been confiscated by any officer of the law or the issuing agency or office due
to the violation of any law, statute, order, rule or regulation.

Despite diligent efforts exerted, I could not locate or recover the said ATM card, and to the best of my
knowledge, the same is truly lost.

In the event that the lost ATM card should hereafter be found or located, I undertake to forward or
surrender the same to Bangko De Oro Bank for appropriate disposal.

Notary Public

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