REPUBLIC OF THE PHILIPPINES )

MEYCAUAYAN CITY BULACAN ) S.S.

AFFIDAVIT OF LOSS

I, JOSE L. SOLERA, Filipino, of legal age, and a resident of No. 004

Ana Maria, Iba, Meycauayan City, Bulacan, after being duly sworn to in
accordance with law, hereby depose and state that:

1. I am a holder of an ATM Card issued by the Philippine National

Bank, the account number of which I cannot remember;

2. The said account is where my pension is deposited;

3. On 15 January 2018, I lost my ATM Card somewhere in the

province of Ilocos Sur;

4. Despite diligent search and efforts exerted to locate the said ATM
Card, I could not find it, such that I now believe that it is now lost and beyond
recovery;

5. Said card is not offered as collateral for any loan;

6. As such, I am executing this Affidavit of Loss to attest to the truth

of the foregoing and to support my application for the issuance of a new ATM
Card, in lieu of the one that I lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 06 th day of

February, 2018 at Meycauayan City, Bulacan, Philippines.

JOSE L. SOLERA
Affiant

SUBSCRIBED AND SWORN to before me this 06th day of February,

2018, affiant satisfactorily proven to me his identity through his Senior citizen
ID No. 19066 and, that he is the same person who personally signed before me
the foregoing affidavit and acknowledged that he executed the same.

Doc No. 183;

Page No. 38;
Book No. II;
Series of 2018.