Republic of the Philippines

)
City of Iloilo
) S.S.
AFFIDAVIT OF LOSS

I, Sakura Haruno, of legal age, Filipino, single/married, and resident of

Aurora Subd., Iloilo City, after being duly sworn according to law, hereby
depose and state that:
1. I am the holder of
ATM Card No. 12345678 issued by the
Metropolitan Bank Roxas City Branch on July 10, 2008at Roxas
Boulevard, Roxas City, Capiz;
2. Sometime in February 2016 I lost the above ATM Card under the
following circumstances: I was withdrawing money from an ATM
machine in an outlet in Iloilo. When I was riding a taxi going home, I
realized my ATM was nowhere to be found;
3. Despite diligent efforts exerted, I could no longer locate, find or
recover the said ATM Card and to the best of my knowledge, the same
is truly lost;
4. The said ATM Card has not been confiscated by any officer of the law
or the issuing office or agency due to the violation of any law, statute,
order, rule or regulation;
5. In the event that the lost ATM Card should hereafter be found or
located, I undertake to forward or surrender the same to Metropolitan
Bank Roxas City Branch for appropriate disposal;
6. I am executing this Affidavit to attest to the truth of the foregoing
statements and to request the issuance of a ATM Card in lieu of the one
which was lost;
IN WITNESS WHEREOF, I have hereunto affixed my signature this 5 th
day of March of 2016.

Sakura Haruno
Affiant
CTC No. : _______________
Issued at: _______________
Issued on: ______________
SUBSCRIBED AND SWORN to before me this 5th day of March 2016,
affiant exhibiting to me her Community Tax Certificate above-written.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______.

Atty. MA. RHENEE ANN G. PENIANO

Avancea Village, Brgy. Dulonan, Arevalo, Iloilo City
Roll No. 39393 IBP No. 9911 dated 9-9-11

MCLE Compliance No. 11-00043527

NOTARY PUBLIC