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AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES )


CITY OF CEBU) S.S.

I, Juana De la Cruz, of legal age, single, residing at Basak,


Pardo, Cebu City after being sworn to in accordance with law, depose
and say THAT:
1. I am the holder of Automated Teller Machine (ATM) Card No.
______________ issued in my favor by XYZ Bank ____________
branch.
2. I used to put the said ATM card in my locker at
Teleperformance Building, Aegis Tower 1, Villa Street, IT Park
Lahug, Cebu City. On September 25, 2015 at about 6:00 AM, I
could not find the ATM in my locker;
3. Diligent effort to locate the same proved futile;
4. In view thereof, I now desire and hereby request XYZ Bank to
issue another ATM card in lieu of the lost one.
5. I bind myself to save XYZ Bank harmless from any loss or
damage that it may incur in connection with the issuance of a
new ATM card in lieu of the lost one.
6. I am executing this affidavit to attest to the foregoing facts and
for any legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this
__________________ in the City of Cebu, Philippines.

Juana De la Cruz
AFFIANT

SUBSCRIBED
and
sworn
to
before
me
this
_______________________________, in the City of Cebu, Philippines affiant
exhibiting to me her valid proof of identification _______________________
issued on ___________________ at ____________________________.
Doc. No. ____
Page No. ____
Book No. ____
Series of 2015.

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