REPUBLIC OF THE PHILIPPINES)

CITY OF PAGADIAN ) S.S.

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

AFFIDAVIT OF LOSS

I, ____________, of legal age, Filipino and a resident of

_____________, after having been duly sworn to in accordance with law,
depose and state:

1. That I maintain a Savings Account ATM Card with

__________________;

2. That sometime last ___________, the ATM card which has always
been in my possession was lost and its whereabouts cannot be
ascertained.

3. Despite diligent efforts exerted, I could no longer locate, find or

recover the ATM card, and to the best of my knowledge, the same
are truly lost;

4. In view thereof, I now desire and hereby request

______________________ to issue another ATM in lieu of the lost
one and I am willing to surrender the lost ATM card in the event
that the same could be found;

5. As such, I am executing this affidavit to attest to the foregoing facts

and to support the application for the issuance of an ATM card in
lieu of the one which were lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day

of June 2017 in Pagadian City, Philippines.

__________________
Affiant

SUBCRIBED AND SWORN TO before me this 13th day of June 2017

in Pagadian City, Philippines, affiant exhibiting to me her valid proof of
identification.