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Notarization is required.

Affidavit of Loss

Passbook ATM Card Certificate Manager’s Check Others , please specify

I/We ( the “Affiant/s”),

married/ single, of legal age, now residing at

after being duly sworn to in accordance with the law, do hereby depose and state THAT :

1. I/We am/are accountholder/s of BDO Unibank, Inc ______________________________________ Branch ( the “Bank”) ;
2. I/We am/are the lawful holder/s of the _____________________________(the “Subject”) with the following particulars :
_______________________________________________________________________________________________________________________
3. I/We am/are the rightful owner/s of Subject and the funds covered thereby and the same was not assigned , conveyed or ceded in favor of a third
party ;
4. Subject was lost/ stolen/ destroyed under the following circumstances :
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
5. Diligent efforts to retrieve/recover Subject proved futile;
6. I/We hereby agree jointly and severally to hold BDO Unibank, Inc., its assigns, officers and employees free and harmless from any liability and
indemnify them for any loss or damage they may suffer as a consequence of the eventual delivery to me/ us of the proceeds of said amount;
7. For lost / stolen / destroyed Manager’s Check, attached hereto and made an integral part hereof, is the supplementary affidavit executed or caused
to be executed by the Payee concerning the loss of physical possession of the Manager’s Check;
8. This Affidavit is executed to attest to the truth of all the foregoing statements and to serve as basis for the following request/s :

__________ Immediate closure of the above account and opening of a new one
__________ Issuance of a new passbook / card in lieu of the lost one under the same account number
__________ Renewal/roll-over/pre-termination of the TD Certificate / Placement Advice / Certificate of Participation/ Confirmation of Sale
__________ Cancellation of the manager’s check and issuance of a replacement check
__________ that the following changes be effected in all the records of the bank for the indicated Account/ Customer Number :
Account / Customer No. :
[ ] Add [ ] Change [ ] Delete
From :
To :
__________ others

9. I /We am/are willing to testify in any court of justice to substantiate the truth and veracity of each and all of the foregoing facts;
10. This Affidavit will serve as my / our unqualified undertaking and/or of the corporation or entity represented by me/us if such is the case, to hold the
Bank free and harmless from any loss or liability of whatever nature that it may incur or stand to incur by reason of or as a consequence of acceding
to my/our request including but not necessarily limited to the obligation to honor in the hands of a holder in due course the Subject said to be lost,
destroyed or stolen ;
11. I /We undertake to surrender Subject to the Bank for proper disposition in the event that the same should be found and located.

IN WITNESS WHEREOF , I / we have set my/our hands at ____________________________ Philippines on this ______day of _____________, 20____.

Declarant Signature Over Printed Name Declarant Signature Over Printed Name Declarant Signature Over Printed Name

Signed in the Presence of:

SUBSCRIBED AND SWORN TO before me this _______day of _____________, 20____ in __________________ Philippines, affiant/s exhibited to
me his/her/their ___________________________ issued at _______ on _________ and Community Tax Certificate No. ______________issued in
________________on _______________, 20____.

NOTARY PUBLIC
Until __________________
Doc. No.
Page No.
Book No.
Series of :

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