REPUBLIC OF THE PHILIPPINES)

CITY OF PASIG ) S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, and a resident of, after having been duly sworn in
accordance with law, hereby depose and state:

1)
2) That I am executing this affidavit to attest to the truth of the foregoing facts, for
the issuance of a new ATM and for any other legal purpose this may deem proper.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 19 of March

2018.

Affiant

SUBSCRIBED AND SWORN to before me this affiant exhibiting to me his as

competent evidence of affiant’s identity.

Notary Public

Doc. No.
Book No.
Page No.
Series of 2018.