REPUBLIC OF THE PHILIPPINES )

Tagbilaran City ) S.S

x---------------------------------x

AFFIDAVIT OF LOSS

I, CARMEN A. LIBATON, Filipino, of legal age,

married, Filipino citizen and a resident of San Isidro, Bohol,
Philippines, after having been duly sworn to in accordance
with law, do hereby deposes and states:

1. That I am a holder of ATM CARD issued by Union

Bank, Tagbilaran City Branch;

2. That said ATM CARD was accidentally lost

sometime on September 2019 at San Isidro,
Bohol, Philippines, and despite diligent efforts to
locate it, the same could not be found and beyond
recovery;

3. That I am executing this affidavit to attest into the

fact of loss of said ATM CARD for legal purposes;

IN WITNESS WHEREOF, I have hereunto set my

hand this 14th day of October atTagbilaran City.

CARMEN A. LIBATON
Affiant
PhilHealth ID No: 12-000053851-0
Issued by PhilHealth

SUBSCRIBED AND SWORN to before me this 14th day

of October 2019 at Tagbilaran City, Bohol, Philippines.

Doc No. ____

Page No. ____
Book No. III
Series of 2019