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REPUBLIC OF THE PHILIPPINES) ___________, METRO MANILA )S.S.

AFFIDAVIT OF LOSS I, ___________, Filipino, of legal age, and with office address at ___________________, Makati City, after having sworn in accordance with law hereby depose and say that: 1. I am the _(cite position)__ of _______________ (the Bank for brevity). As _(cite position)_, I am tasked, among others, to _(cite functions)___. In the course of the performance of my functions, I (cite circumstances prior to loss). When I was about to _(cite how the discovery of loss was made)____, I noticed that the _(cite item lost)___ was missing. Despite diligent search and inquiry to date, the _(cite item lost)__ still cannot be found. I am executing this affidavit to attest to the truth of the foregoing and for whatever legal purpose it may serve me and ___. FURTHER AFFIANT SAYETH NAUGHT. IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of __________ 2011 at ___________, Metro Manila. ___________________ xxx SUBSCRIBED AND SWORN to before me this ___ day of ____ 2011, affiant exhibiting to me her Passport No. _____________ issued on ________ at ________________.

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NOTARY PUBLIC Doc. No. ____ Page No. ____ Book No. ____ Series of 2011.

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