R e p u b l i c o f t h e P h i l i p p i n e s )

City of _______________ ) S.S.

AFFIDAVIT OF LOSS

I, Mary Grace S. Ruña , o f l e g a l a g e , F i l i p i n o , a n d w i t h r e s i d e n c e 1 1 0 B

3 2 E x c e s s L o t S i l 1 D a s m a r i n a s , C a v i t e , a f t e r having been sworn to oath
in accordance with law, hereby depose and state;

T h a t I a m a h o l d e r o f t h e M e t r o b a n k a t m w i t h a c c o u n t number
(_______________________)issued by Metrobank Manggahan.

That sometime last Saturday, when I arrived home from

w o r k , I discovered that my wallet in my pocket with METROBANK ATM
card was no longer in my pocket where I used to place it;

That despite diligent search and efforts to locate my wallet with my

metrobank atm card, I c o u l d n o t f i n d t h e s a m e s u c h t h a t I n o w b e l i e v e
t h a t i t i s n o w lost beyond recovery;

S a i d A t m C a r d w a s n o t c o n f i s c a t e d b y a n y o f f i c e r o f t h e l a w o r the
officers of Metrobank by reason of any violation of any law,o r d i n a n c e ,
p r e s i d e n t i a l d e c r e e o r r u l e s a n d r e g u l a t i o n o f s a i d bank and; neither
was it offered as collateral for any loan;

Th a t I a m e x e c u t i n g t h i s a f f i d a v i t t o a t t e s t t o t h e t r u t h o f t h e
foregoing facts and to request for a replacement of
my Metrobank atm Card.

IN WITNESS WHEREOF, I have hereun to affixed my signature this

____________________________

Mary Grace S. Ruña

Affiant

Subcscribed and Sworn to before me, this _____________ day of ___________________ in

____________________________ City, with affiant exhibiting his CTC No. ________________________, Issued
on _____________________ at ___________________________Doc. No.:__________________;

Doc. No.:__________________;
Page No.:__________________;
Book No.:__________________;
Serial of .;__________________;