Republic of the Philippines)

City of Legazpi ) s.s.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, JOEUIE CAO DELA CRUZ, of legal age, Filipino citizen, single

and with residence and postal address at Purok 1, Poblacion, Rapu-
Rapu, Albay, after having been duly sworn in accordance with law do
hereby depose and state:

1. That I am a holder of a UNION Bank ATM Card with Account

Number 100248035221.

2. That above-mentioned card where kept inside my wallet.

However, when I tried to use the said card I noticed that it
was no longer in my wallet, either the same dropped or fell,
without my knowledge.

3. But when I try to look for the said ATM Card, I can no longer
locate the same despite diligent efforts made and considered
lost for all intent and purposes.

4. That I am executing this affidavit to attest the truth of the

foregoing statements and for the purpose of complying with
the requirements replacing said ATM Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 4th day

of May 2017 at Legazpi City, Philippines.

JOEUIE CAO DELA

CRUZ
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of May

2017 at Legazpi City, Philippines. Affiant exhibited to me his One Half
Staffing Solution Identification Card with number 2015-274 bearing his
photograph and genuine signature as competent proof of identity.

Doc. No. _____;

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