REPUBLIC OF THE PHILIPPINES )

CITY OF TAGBILARAN ) S.S.

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, single, Filipino, with residence at

Palma St., Poblacion II, Tagbilaran City, Bohol after having been sworn to in
accordance with law hereby depose and say that:

1. That I am a holder of Automated Teller Machine (ATM) Card No.

123456789012, issued by Bank of the Philippine Islands (BPI) on
August 19, 2019 in Tagbilaran City;

2. That I used to keep said ATM card in my wallet;

3. That on January 4, 2021, when I arrived home from work, I found out
that said ATM card was no longer in my wallet;

4. That I have exerted diligent efforts to locate the said ATM card to no
avail;

5. That I bind myself to save BPI harmless from any loss or damage that
it may incur in connection with the issuance of a new ATM card in lieu
of the lost one;

6. That I execute this affidavit to attest the truthfulness and veracity of

the foregoing facts, and for the purpose of securing another ATM Card
from the same bank, in place of the lost one, and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto signed my name this 8 th

day of January 2021, in Tagbilaran City, Philippines.

JUAN DELA CRUZ

Affiant
         
      SUBSCRIBED AND SWORN to before me this 8th day of January
2021 in Tagbilaran City Philippines. Affiant exhibited to me his Driver’s
License with License No. G24-12-345678.

Notary Public
Doc. No____;
Page No. ___;
Book No. ___;
Series of 2021.