Republic of the Philippines )

__________________________________ )s.s.
x----------------------------------------------x

AFFIDAVIT OF LOSS
I, _________________, of legal age, Filipino, single and a resident of
_______________________________, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. I am a holder of an ATM Card issued by Chinabank, _______________________________;

2. I have always kept all my important belongings such as ATM Cards in a pouch
which I have used for a long time already;

3. On _______________________________, while we are travelling around

_______________________________, I remember using the same for a couple of times.
Upon returning back home, I was shocked when I could no longer locate the
pouch inside my bag which contains the above-mentioned ATM Card;

4. Immediately, I had exerted diligent efforts to locate the same in all the places
where such could possibly be found as aided by members of our household.
Despite all such efforts, the same could no longer be located such that I had
eventually deemed the same as forever lost; and

5. I executed this statement to attest to the truth of the foregoing facts for all legal
purposes this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________________________ at _______________________________, Philippines.

_______________________________
Affiant
_______________________________

SUBSCRIBED AND SWORN to before me on the date and place as stated above.

Doc. No. ______;

Page No.______;
Book No. ______;
Series of 2023.