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Republic of of the Ph Philippines City of Ormoc
) ) S.S.
AFFIDAVIT OF LOSS
I, BENJAMIN S. PONGOS, JR., of legal age, Filipino, single and with reside residence nce at !! "onif "onifaci acio o #$tens #$tension ion,, %istri %istrict ct !&, Ormoc Ormoc City, City, 'eyte, 'eyte, after after ha(ing been sworn to oath in accordance with law, hereby depose and state
!. *hat *hat I am a hold holder er of the the '+% '+%"+ "+- +* card card with accou account nt number /012/1!32& issued by 'andban4 Ormoc "ranch5 3. *hat *hat some someti time me last last wee4 wee4,, when when I arri arri(e (ed d home home from from wor4 wor4 I disco(ered that my '+%"+- +* card was no longer in my wallet where I used to place it5 6. *hat despite despite dilige diligent nt search and and efforts efforts to locate locate my +* Card, Card, I could not find the same such that I now belie(e that it is now lost beyond reco(ery5 7. Said Said +* Card was not not confisca confiscated ted by any office officerr of the law law or the officers of '+%"+- by reason of any (iolation of any law, ordinance, presidential decree or rules and regulation of said ban45 and neither was it offered as collateral for any loan5 1. *hat *hat I am e$ecu e$ecuti ting ng this this affid affida( a(it it to atte attest st to the the trut truth h of the fore forego goiing fact facts s and and to re8u re8ues estt for for a repl replac ace ement ment of my '+%"+- +* card. I 9I*#SS 9:#R#OF, I ha(e hereunto affi$ed my signature this ;; day of
BENJAMIN S. PONGOS, JR.
+ffiant
Subscribed and sworn to before me this ;;; day of
%oc. o. ;;;;;5 Page o. ;;;;;5 "oo4 o. ;;;;;5 Series of 3/!2.