Republic of the Philippines )

__________________________ ) S.S.

AFFIDAVIT OF CAPTURED
ATM CARD
I, LEAHVEY A. CELEBRE, of legal age, Filipino citizen, married and a resident of
Phase 1-B, Block 11, Lot 32, Southville 2, Brgy. Inocencio, Trece Martires City, Cavite,
after being duly sworn to in accordance with law, hereby depose and state that:

1. I am the registered holder of a certain RCBC ATM Card under my Account

bearing No. 9012071294;

2. However, on November 10, 2017 at about 6:00 P.M. at RCBC Trece Martires
City Branch, when I tried to withdraw certain amount of cash, I was surprised
when my ATM card was captured by the ATM Machine and as such, I was not
able to effect a withdrawal;

3. I have tried to secure the above-stated item but the same proved futile despite
diligent efforts on my part. Thus, taking into account the nature of the loss of
the said item and since my ATM Card does not contain my name and only the
pertinent numbers are indicated therein, it is reasonable to consider such item
as completely lost and beyond recovery;

4. In view thereof, I am executing this Affidavit to attest to the truth of the

foregoing statements, to secure a replacement of my ATM Card and for whatever
legal intents and purposes this affidavit may serve.

FURTHER AFFIANT SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand and affix my signature

this _____________________________ at ______________________________.

LEAHVEY A. CELEBRE
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of

_________________________ at ______________________________, affiant exhibiting to me
her BIR TIN: 224-338-480-000 issued at Trece Martires City, Cavite, which serves as
her Competent Evidence of Identity pursuant to the 2004 Rules on Notarial Practice.

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 2017.