Republic of the Philippines

City of Manila, Metro Manila

) S.S.

Affidavit of Loss
I, Manuel Jarabe Muhi, Jr., of legal age, married, Filipino and resident of
No. 9 Alpine Lily Street, Anastacia Village, Nangka, Marikina City, having
been duly sworn in accordance with law, hereby depose and state:
1. That I have an account with BPI Bank with Account No. 3179-207019 with an ATM card issued by BPI Marikina Branch;
2. That my nephew, Manuel Bong M. Muhi, was the keeper and
custodian of the card;
3. That on year 2012, I instructed my nephew to withdraw cash from
one of the ATM machine of BPI in Bayan-Bayanan, Concepcion
Branch, Marikina using my ATM card. However, after the transaction,
the ATM machine captured my card;
4. That despite diligent efforts to recover the said ATM card, I could not
recover the said card and it is now lost beyond recovery;
5. That my ATM card was not deliberately disposed or lost, and likewise
not for any purpose contrary to law; and
6. As such, I am executing this Affidavit of Loss to attest the truth of the
foregoing and to support my application for the issuance of new ATM
card in lieu of the one that has been lost.

IN WITNESS WHEREOF, I have set my hand this ____ th day of July 2016,
in Sta. Mesa, City of Manila, Metro Manila, Philippines.

SUBSCRIBED AND SWORN to before me this day of _____, 2016, the

affiant personally appear to me and exhibiting to me his ID____________
_______________ issued at __________ on __________.

Notary Public
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Doc. No._______;
Page No._______;
Book No._______;
Series of 20_____.

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