Republic of the Philippines )

Tacloban City, Leyte ) S. S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, MONA LISA, of legal age, Filipino, single, and a resident of R506, Crystal Towers, Kassel
City Subd., Brgy. Abucay, Tacloban City, after having been sworn in accordance with law, hereby
deposes and states the following:

1. I am holder and owner of the this passport as my competent evidence of

identification;

2. I have recently lost my UPB ATM Card with account number of 1092849921 and can
no longer be found or retrieved despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

MONA LISA
Affiant

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below.
The affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________,

Philippines.

WITNESS MY HAND AND SEAL.