Republic of the Philippines )

Province of Leyte ) s.s.

AFFIDAVIT OF LOSS
I, ___________, Filipino, of legal age, and a resident of ______________________ ,
after having been duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of a XXXX ATM Card registered under my name and issued
by XXXXX, XXXXX;

2. That I used to put said identification card in my pouch;

3. That sometime on the first week of XXXXX, when I arrived home from work, I
discovered that XXXXXX was no longer in my pouch where I used to place it;

4. Despite diligent search and efforts to locate said XXXXXX, I could not find it;

5. I have recently discovered the said XXXXX is irretrievably lost and can no longer
be found despite diligent efforts to locate the same;

6. That I am executing this affidavit to attest to the truth of the foregoing facts and
to request for a replacement XXXXX;

IN WITNESS WHEREOF , I have hereunto affixed my signature this _____________

at XXXXX, Philippines.

XXXXXXXXXXXXXX
Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for XXXX and
the XXXXX, this _____________ the affiant, exhibited to me her competent evidence
of identity: XXXXXX issued by XXXXXXX, XXXXX, personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of the
contents of said instrument.

Doc. No. ........; Notary Public

Page No. .......;
Book No. …….;
Series of 2018.