REPUBLIC OF THE PHILIPPINES )

City of __________ ) S.S

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

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ of legal age, Filipino, single, and a resident of ADDRESS,
Philippines after having been duly sworn in accordance with law, hereby depose and
say THAT:

1. I am a holder of an Automated Teller Machine (ATM) Card No. 1234567890 duly

issued in my favor by NAME OF BANK in _____City;

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

3. Sometime in the morning of July 29, 2023, when I was about to withdraw from an
ATM in __________ City, I discovered that my ATM card was no longer inside
my wallet where it is usually placed;

4. I immediately searched for the said ATM card in my bag and all other places at
home where I may have left the same;

5. I failed to find and recover my ATM card despite diligent search and earnest
efforts to locate the same, and I consider it as lost and can no longer be found;

6. In view thereof, I now desire and hereby request NAME OF BANK to issue
another ATM card in lieu of the lost one;

7. I am executing this Affidavit to attest to the truth of the foregoing facts and in
support of my application for the replacement of the said ATM card and for
whatever legal intents and purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 1 st day of

August 2023 in Iloilo City, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me this 1st day of August 2023 in

______________, Philippines, affiant exhibited his Driver’s License No. 0987654321
bearing the affiant’s photograph and signature, through which his identity was
confirmed.

Doc No. _______;

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