AFFIDAVIT OF LOSS

(ATM Card)

Republic of the Philippines )

[place] ) S.S.

I, NAME, of legal age and residing at address,  after having been duly sworn to in
accordance with law, do hereby depose and state that:

1. I am a holder of an ATM card from [bank] for the purposes [indicate the
purpose];

2. On [date], I discovered that my ATM card was missing;

3. Despite diligent search, I could no longer locate it and consider it beyond

recovery; and

4. I am executing this Affidavit of Loss to attest to the truth of the foregoing facts,
to get a new ATM card from [bank] and to use the same for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this [date] at [place].

[NAME]
Affiant
ID # _________________

SUBSCRIBED AND SWORN to before me on this [date], in [place], affiant exhibiting

before me his/her competent proof of identity above-indicated.

Doc No. ________;

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