Affidavit of Loss Sample – ATM

Affidavit of loss is a common document executed to establish the loss of personal property. Below is the sample format:

Republic of the Philippines )
City of Makati ) S.S.

AFFIDAVIT OF LOSS

I, MS. AFFIE DAVIT, of legal age, single, Filipino, and a resident of 111 D. Villanueva St. Sta. Lucia San Juan City, after having been duly sworn to, in accordance with law, do hereby depose and state that

1. I am a holder of BDO ATM Card issued to me as an employee of XYZ Company Inc.;
2. On or about November 20______, I was riding the jeepney on my way home when I noticed that my wallet was missing which contained my said BDO ATM card;
3. I exerted efforts to locate it in every possible place I could put it but to no avail;
4. If I ever I will find it in the future I will inform the proper parties/authority about it;
5. I am executing this document to attest to the foregoing statements and for the purpose of obtaining replacement of the said ATM.

Ms. AFFIE DAVIT
Affiant
ID: _________________________

SUBSCRIBED AND SWORN to, this ____th day of December 20____, the affiant personally appeared and presented to me her competent evidence of identity shown above.

Doc. No.: __________;
Page No.: __________;
Book No.: __________;
Series of 20____