Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, VICTOR P. ESPAÑOL, Filipino, married, of legal age, resident of Barangay San

Pedro I, Malvar, Batangas, Philippines, after having been sworn by law hereby depose
and state that:

1. I am the owner of an ATM Card issued by the Union Bank of the Philippines;

2. Sometime on March 15, 2024, in our place, 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 and Identification card have 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. If the lost ATM card should hereafter be found or located, I undertake to forward or
surrender the same to the company where I worked 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.

IN WITNESS WHEREOF, I have hereunto set my hand this 3 rd of July, 2024, in Malvar,
Batangas, Philippines.

VICTOR P. ESPAÑOL
Affiant
Issued ID: Senior Citizen
ID No. 9661

SUBSCRIBED AND SWORN to before me on this 3rd day of July 2024, in Malvar,
Batangas Philippines.

Doc. No. ;
Page No. ;
Book No.
; Series of 2024.