Republic of the Philippines)

City of Makati ) S.S.

AFFIDAVIT OF LOSS

I, JOHN DOE, of legal age, Filipino, and with residential address

at Lot 4C Block 5 Greenwest Village, Cainta, Rizal, after having
been duly sworn in accordance with law, hereby depose and state
that:

1. I am the owner of the ABC Credit Card under

Customer No. 12345, issued in my favor by said back
on June 16, 2015 in Makati City;

2. That I used to put said credit card in my wallet;

3. That sometime on April 20, 2017, when I arrived home

from work, I discovered that said Credit Card was no
longer in my wallet;

4. That diligent effort to locate the same proved futile;

5.
6. That in view thereof, I now desire and hereby request
ABC Bank to issue another credit card in lieu of the
lost one

7. I am executing this affidavit to attest to the truth of

the foregoing facts, and for whatever legal purpose it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this 21st day of April 2017 in Makati City, Metro
Manila, Philippines.

JOHN DOE
Affiant
Voter’s ID No. 5555

BEFORE ME, appears the person of JOHN DOE presenting

the above Affidavit, who is personally known to me or identified by
me through competent evidence of identity as defined by the
Notarial Rules as the person who signs the document and in my
presence taken an oath or affirmation before me as to such
document.

WITNESS MY HAND AND SEAL this day 21 of April, 2017 in

Makati City.
Doc. No.
Page No.
Book No.
Series of 2019.