FORM A- Rev .

2018
Affidavit of Loss/Circumstance/Ownership
Republic of the Philippines)
Municipality/City of ______________ ) S.S.
Province of ____________ )

AFFIDAVIT OF LOSS/CIRCUMSTANCE/OWNERSHIP

I, __________________________________________, after having been duly sworn to in accordance with law, do

hereby depose and say that:

1. I am of legal age, single/married and a resident of ________________________________________________

_______________________________________________;

2. I am the bonafide owner of Certificate of Time Deposit/Savings/Current Account No/s.

___________________________ (“the account”) issued by the closed _________________________________
___________________________ (name of closed bank);

3. I am in possession of the account/s since the date of opening of said account/s and there exists no
conflict or dispute arising from my ownership and possession of the account/s;

4. The account/s is/are my legitimate deposit/s with the bank;

5. The closed bank issued to me Passbook/ATM/Certificate of Time Deposit/ Checks/ Bank Statement (“the
evidence of deposit”);

6. The evidence of deposit was ____________________________________________________________________

(state circumstances surrounding the absence of the document) and despite diligent search, said
evidence of deposit can no longer be found;

7. I have filed claim/s for insured deposit/s with the Philippine Deposit Insurance Corporation (PDIC);

8. I shall be held personally liable to any person, natural or juridical, that may be prejudiced by my
representations, in addition to other liabilities, civil or criminal, that may arise therefrom; hereby
releasing and discharging PDIC from any and all further obligations in connection with this claim;

9. I undertake to refund PDIC the amount paid to me including interest thereon and indemnify PDIC, the
bank and/or third parties for any loss or damages occasioned by such payment;

10. I declare under penalty of perjury under the Revised Penal Code and under Section 26 (h)(1) of
Republic Act No. 3591, as amended, the truthfulness, accuracy and genuineness of all the information,
documents and records attached to this claim, and I stand liable should I be found to have made
herein misinterpretation or fraudulent declaration;

11. It is understood that personal information processed by PDIC as a result of submission of this
document will be used for the purpose of verification and settlement of claims against the closed
bank and may be shared with other government offices or third parties as may be required by law or
lawful order in relation to the performance by PDIC of its mandates to promote and safeguard the
interests of the depositing public and help maintain a sound and stable banking system. It is
acknowledged that PDIC implements adequate measures to uphold the rights of its data subjects
including its employees and protect personal data in compliance with the Data Privacy Act of 2012.

I am executing this affidavit to attest to the truth and veracity of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ day of

_______________________________ at _________________________________.

Affiant

SUBSCRIBED AND SWORN to before me in the Municipality/City of ________________________ this

________ day of _____________________________ by the affiant, who has satisfactorily proven his/her identity to me
through his/her _________________________________ issued on _________________ in _________________, that he/she is
the same person who personally signed the foregoing affidavit before me and acknowledged that he/she
executed the same.

Notary Public
Doc. No. __________;
Page No. __________;
Book No. __________;
Series of __________;