REPUBLIC OF THE PHILIPPINES ) CITY OF MAKATI ) ippi L AFFIDAVIT OF LOSS » Filipino, single, of legal age, resident of. : ines, afer having been swom in accordance with law hereby depose and state that: I am the owner of ATM Card No. issued by the (bank). Sometime around. . I lost the above ATM Card under the following circumstances: 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. The said ATM Card has 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, In the event that the lost ATM card should hereafter be found or located, I undertake to forward or surrender the same to_(bank) for appropriate disposal. Tam 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. SUBSCRIBED AND SWORN to before me this day of . 20__, affiant exhibiting to me his competent evidence of identity by way of ___(D Type and number) issued at City on. Doe No. Notary Public Page No, : Book no, Series of f20__