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REPUBLIC OF THE PHILIPPINES  )

CITY     OF      DAVAO                  )SS.

X-----------------------------------------X

 

 

AFFIDAVIT OF LOSS

 

I, (insert name here), Filipino, of legal age, single and a resident of (insert address here), Philippines, after having duly sworn to in accordance with law,  hereby depose and say that:

 

1.     I am the holder of an Automated Teller Machine card number (insert number here) issued by (insert name of bank here);

 

2.     I lost said ATM on (insert date here) and that I exerted all efforts to locate the same but I could not remember exactly where I placed/left it and it is considered lost for all legal purposes;

 

3.     Said ATM Card was not confiscated by any officer of the law or the officers of (name of bank) by reason of any violation of any law, ordinance, presidential decree or rules and regulation of said bank; and neither was it offered as collateral for any loan;

 

4.     I am executing this affidavit to attest to the foregoing facts;

 

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in the City of ___________, Philippines.

 

 

                                                                   (Insert Name of Affiant)

     Affiant

 

 

SUBSCRIBED AND SWORN to before me this _______________ in the City of ____________ Philippines, affiant having exhibited to me (his or her) community tax certificate with no. _______________  issued on ______________ at _____________.

 

Doc. No.____;

Page No.____;

Book No.____;

Series of 2006.