REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

AFFIDAVIT OF LOSS

I, ___ , Filipino, of legal age, residing at ______________, after having been sworn in accordance
with law hereby depose and state:

1. That on _____________, I was looking for my Debit Card but to my surprise, said
debit card cannot be found;

2. Said debit card is used for the payroll of the company _______________.

3. That I took pains to look for said debit card by checking my bags and calling in our
home, but to no avail;

4. That I am executing this affidavit to attest to the truth of the foregoing and to request
from _________________-- another issue of a debit card.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of June, 2017 at Makati City,
Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, with affiant exhibiting her Drivers License No. N26-09-0145445,
issued on December 17, 2014 at Manila, Philippines.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.