REPUBLIC OF THE PHILIPPINES)

___________________)
____________________ )SS
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AFFIDAVIT OF LOSS

I, ________________________, Filipino, of legal age, married, and a resident

of ____________________, Philippines, after having been duly sworn to in
accordance with the law, do hereby depose and say that:

1. Sometime in December 23, 2023, I lost my ATM Card linked to my

Savings Account with no. __________________ issued by
_____________________;

2. I kept the said ATM Card in my wallet for safekeeping but unfortunately the
said ATM Card got lost;

3. Despite diligent search and efforts to locate the said ATM Card, I could not
find the same such that I believe that it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to

enable me to secure a replacement for the said ATM Card and to inform the
concerned institutions and offices of the said lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of January
2024 in ________________________, Philippines.

_______________________
Affiant
Driver’s License # _________________

SUBCRIBED AND SWORN TO before me this 9th day of January 2024 in

______________________, Philippines, affiant exhibiting to me her competent
evidence of identity written below her name.

Doc. No. ____;

Page No. ___;
Book No. ____;
Series of _____.

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Affidavit of Loss