AFFIDAVIT OF LOSS

I, (insert name here), Filipino, of legal age, single and a resident of (insert address here), Philippines, after having duly sworn to in accordance with law, hereby depose and say that:

1. I am the holder of an utomated !eller "achine card number (insert number here) under ccount #o. $$$$$$$$$$$$ issued by (insert name of ban% here)& '. !he credit balance of this $$$$$$$$$$$$$$ as of $$$$$$$ , '(()& account is Php

*. I lost said !" on (insert date here) and that I e+erted all efforts to locate the same but I could not remember e+actly where I placed,left it and it is considered lost for all legal purposes& -. !he money represented by the balance to the credit of the account is my personal property and that I have no assignment, transfer or pledge thereof .. /aid !" 0ard was not confiscated by any officer of the law or the officers of (name of ban%) by reason of any violation of any law, ordinance, presidential decree or rules and regulation of said ban%& and neither was it offered as collateral for any loan& ). I am e+ecuting this affidavit to attest to the foregoing facts and for the purpose of securing the issuance to me of a replacement !" card in lieu of the one that was lost& 1. !hat I hereby agree to hold the (name of ban%) its officers and employees, free and harmless and to indemnify it,them for any loss that it,they may sustain by issuing another !" 0ard&

I# 2I!#3// 243536F, I have hereunto set $$$$$$$$$$$$$$ in the 0ity of $$$$$$$$$$$, Philippines.

my

hand

this

$$$$$$$$$$$$$$$ ffiant /78/05I839 #9 /265# to before me this $$$$$$$$$$$$$$$ in the 0ity of $$$$$$$$$$$$ Philippines, affiant having e+hibited to me (his or her) community ta+ certificate with no. $$$$$$$$$$$$$$$ issued on $$$$$$$$$$$$$$ at $$$$$$$$$$$$$. 9oc. #o.$$$$& Page #o.$$$$& 8oo% #o.$$$$& /eries of '(().