AFFIDAVIT OF LOSS ATM CARD 

BASIC PHILIPPINE LEGAL FORMS

When executing an affidavit of loss, it is important that the affiant attest that the thing subject of the affidavit of loss was not confiscated by the officers of the law or officers of the issuing body or agency due to any violation of a law, statute or other rules and regulation. 

REPUBLIC OF THE PHILIPPINES  )

CITY     OF      ________           )SS.

X-----------------------------------------X

AFFIDAVIT OF LOSS

I, (insert name here), Filipino, of legal age, single and a resident of (insert address here), Philippines, after having duly sworn to in accordance with law,  hereby depose and say that:

1.             I am the holder of an Automated Teller Machine card number (insert number here) under Account No. ____________ issued by (insert name of bank here);

2.             The credit balance of this account is Php ______________ as of _______ , 2006;

3.             I lost said ATM on (insert date here) and that I exerted all efforts to locate the same but I could not remember exactly where I placed/left it and it is considered lost for all legal purposes;

4.             The money represented by the balance to the credit of the account is my personal property and that I have no assignment, transfer or pledge thereof

5.             Said ATM Card was not confiscated by any officer of the law or the officers of (name of bank) by reason of any violation of any law, ordinance, presidential decree or rules and regulation of said bank; and neither was it offered as collateral for any loan;

6.             I am executing this affidavit to attest to the foregoing facts and for the purpose of securing the issuance to me of a replacement ATM card in lieu of the one that was lost;

7.             That I hereby agree to hold the (name of bank) its officers and employees, free and harmless and to indemnify it/them for any loss that it/they may sustain by issuing another ATM Card;

       IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in the City of ___________, Philippines.

_______________

Affiant

      SUBSCRIBED AND SWORN to before me this _______________ in the City of ____________ Philippines, affiant having exhibited to me (his or her) community tax certificate with no. _______________  issued on ______________ at _____________.

Doc. No.____;

Page No.____;

Book No.____;

Series of 2006.

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