REPUBLIC OF THE PHILIPPINES) CITY OF LAPU-LAPU---------------------)S.S.

AFFIDAVIT OF LOSS

I,______NAME_____, a Filipino citizen, of legal age, single or married, and a resident of __________Address____________, after having been sworn in accordance with law, hereby depose and say: That I am a holder of the following documents, to wit: (a) Passbook issued to me by Bank of the Philippine Islands or BPI (MEPZ 2 Branch) (b) ATM Card issued to me by Land Bank (UN Avenue Manila Branch) That last March 12, 2013, I lost my wallet containing the said documents and that probably someone took it from my pocket without my consent and knowledge; That I desperately tried and exercised all diligent efforts in order to recover the said documents but all of my efforts were of no avail; That I believe that the said ATM Card and Passbook are now beyond recovery; That I honestly declare that the said ATM Card and Passbook were not seized nor confiscated by any officer of the law or the officers of Bank of the Philippine Islands (BPI) and Land Bank by reason of any violation of any law, ordinance, presidential decree or rules and regulation of said banks. That further, I honestly declare that the said ATM card and Passbook were not delivered to any person or to any banking or financial institution as a collateral or a security for any loan, debt and obligation; That I execute this Affidavit of Loss to attest the veracity and truthfulness of the foregoing facts and for whatever lawful purpose this affidavit may serve best.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this _____day of June, 2013, in the City of Lapu-Lapu, Philippines.

_________NAME_________
Affiant SUBSCRIBED AND SWORN to before me, in the City of Lapu-Lapu this _____day of June, 2013, affiant exhibiting to me his Identification Card enough to prove his identity.

DOC

No. ______________ ----------------------NOTARY PUBLIC----------------------

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