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Affidavit of Loss - ATM

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REPUBLIC OF THE PHILIPPINES)

Quezon City ) SS

AFFIDAVIT OF LOSS

I, ________, of legal age and with current residential address at __________, under
oath, state:

1. That I am a holder of Automated Teller Machine (ATM) Card connected to my bank


account no. _________ duly issued in my favor by Robinson’s Bank, Del Monte
Branch in Quezon City;

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

3. That sometime in September 2022, I discovered that said ATM card was no longer
in my wallet;

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

5. That in view thereof, I now desire and hereby request Robinson’s Bank to issue
another ATM card in lieu of the lost one;

6. That I bind myself to save Robinson’s Bank harmless from any loss or damage that
it may incur in connection with the re-issuance of a new ATM card in lieu of the lost
one;

7. That I am executing this affidavit to attest to the foregoing facts and for any legal
purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 22 August 2023 at Quezon


City.

Affiant

SUBSCRIBED AND SWORN to before me this 22 nd day of August 2023 at


Quezon City, Affiant exhibiting to me his Driver’s License bearing No. ____expiring
on ____.

Doc No. 122;


Page No. 26;
Book No. I;
Series of 2023.

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