REPUBLIC OF THE 

PHILIPPINES)
CITY OF DAVAO                      ) S.c.
x-------------------------------------x
  

AFFIDAVIT OF LOSS 

XXX of legal age, Filipino, single and a resident after having been duly
sworn to in accordance with law, depose and state:

1. That I am a holder of Automated Teller Machine (ATM)) on January 12,

2019 in Davao City;

2. That I used to put said ATM card in my wallet;

3. That sometime on July 20, 2019, when I arrived home from work, I
discovered that said ATM card was no longer in my wallet;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request PNB to issue
another ATM card in lieu of the lost one;

6. That I bind myself to save PNB harmless from any loss or damage that it may
incur in connection with the issuance of a new ATM card in lieu of the lost
one;

7. That I am executing this affidavit to attest to the foregoing facts and for any
legal purpose it may serve.

         IN WITNESS WHEREOF, I have hereunto set my hand this 25th

day of July 2019 in Davao City, Philippines.
          

SUBSCRIBED AND SWORN to before me this 25th day of July

2019 in the City of Davao, Philippines, affiant exhibiting to me his
competent evidence of identity by way

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.