REPUBLIC OF THE PHILIPPINES )

CITY OF MAKATI )

AFFIDAVIT OF LOSS

I, ___________________, Filipino, single, of legal age, resident of___________________,

Philippines, after having been sworn in accordance with law hereby depose and state that:

1. I am the owner of ATM Card No. ________________ issued by the

_______________(bank).
2. Sometime around______________, I lost the above ATM Card under the following
circumstances:

3. Despite diligent efforts exerted, I could not locate or recover the said ATM card, and to
the best of my knowledge, the same is truly lost.
4. The said ATM Card has not been confiscated by any officer of the law or the issuing
agency or office due to the violation of any law, statute, order, rule or regulation.
5. In the event that the lost ATM card should hereafter be found or located, I undertake to
forward or surrender the same to __(bank)____for appropriate disposal.
6. I am executing this affidavit to attest to the truth of the foregoing and to request the
issuance of a new ATM card to replace the one that was lost.

SUBSCRIBED AND SWORN to before me this_____ day of_________ , 20___, affiant

exhibiting to me his competent evidence of identity by way of _____(ID Type and number)___
issued at ___________City on____________.

Notary Public

Doc No. ________;

Page No. _______;
Book no. _______;
Series of 20____.