FORM NO.

36
Another Form of Affidavit of Loss

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF) s.s
CITY OR MUNICIPALITY OF
AFFIDAVIT OF LOSS
I, (state name and personal circumstance of affiant), after having duly sworn, depose and say,
that:

1. I am a depositor of (name of bank and address of branch of account) under (kind of

account) with Account Number ____________; and as such I was issued a passbook and/or ATM card.

2. I used to keep my said passbook and/or ATM card in my table drawer at my office at
__________________. Just recently, I discovered that my said passbook and/or ATM card was
missing. Thinking that it could have been misplaced, I tried to locate it; but despite diligent efforts, I
could not locate it; hence I have considered the same to have been lost and beyond recovery.

3. I have executed the foregoing to attest to the truth of the above averments; and to inform
the said bank of such lost and for issuance of a new savings passbook/ATM card in lieu of the lost one;
and for all legal intents and purposes.
IN WITNESS WHEREOF, 1 have hereunto affixed my signature this __th day of_______
at____________.

(Affiant)

JURAT

(Signature and Seal of the Notary Public)

(FORM NO. 1)