REPUBLIC OF THE PHILIPPINES)

DONE: BAGUIO CITY

) S.S.
AFFIDAVIT OF LOSS
(ATM)
I, JUNEBIL C. SACLA, of legal age, married, Filipino Citizen, with
residence and postal address at No. 5 Flowershop Extension, City Market,
Magsaysay Ave., Baguio City, after having been duly sworn to in accordance
with law do hereby depose and states that:
1. I am a holder of a METROBANK ATM;
2. Sometime in September 18, 2014, the said ATM was lost/missing, it
slipped out from my wallet after using it;
3. I exerted diligent effort to retrieve the said ATM, the same could no
longer be found and hence considered forever lost;
4. Said ATM was never given nor pledged to anyone for any purpose
whatsoever, nor was it taken or confiscated by the authorities for any
violation of the law;
5. I am executing this affidavit to attest to the veracity and truthfulness
of my foregoing statements and to secure a new ATM Card in lieu of
the lost one and for other lawful intents and purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of
September, 2014 at Baguio City, Philippines.
JUNEBIL C. SACLA
Affiant
PhilHealth ID No. 04-050148082-9
SUBSCRIBED AND SWORN TO before me this 26th day of September,
2014 at Baguio City, Philippines. Affiant personally appeared before me and
known to me personally and to be the same person who freely executed and
signed this instrument.
Doc. No. 204;
Page No. 41;
Book No. 9;
Series of 2014.