Republic of the Philippines )

City of Naga )S.S.

AFFIDAVIT OF LOSS

I, ___________________, of legal age, married and with office address at

__________________, after having been duly sworn in accordance with the law, hereby depose
and state, THAT:

1. I am the _____________________ of ________________________ with address at the

_______________________;

2. As such, I am the one who receives and safe keeps ATM Cards before the same is released
to individual clients;

3. On July 2019, I received the following ATM Cards:

a.
b.
c.
d.
e.
f.
g.

4. Said ATM Cards were placed inside an envelope. However, when I checked recently, the
ATM Cards cannot anymore be found;

5. I exerted diligent efforts to locate the said ATM cards but to no avail;

6. I am executing this affidavit to attest to the truth of the foregoing and for whatever legal
purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 15th day of August, 2019 in
the City of Naga, Philippines.

Affiant

SUBSCRIBE AND SWORN TO before me this day of __________ 2019 at Naga

City, Philippines, affiant exhibiting to me her competent evidence of identity with Valid
I.D no. SSS ID _____________

Doc No. _____

Page No._____
Book No. ____
Series of 2019