AFFIDAVIT OF LOSS  

I,   TANDANG SORA, Filipino, of legal age, married, resident of Jaro Iloilo City, Philippines, after having been duly sworn to in accordance with law, depose and say:

That I maintain a regular savings  under Account No. 111-11-111-111-1 with the Opportunity Kauswagan (OK) Bank, Jaro Iloilo City and I was issued an ATM card for said account;

That my said ATM card was lost and despite diligent search it was not found;

That I am executing this affidavit to attest to the foregoing facts for all legal purposes                   IN WITNESS WHEREOF, I have hereunto set my hand this  November 25, 2011  in Kalibo, Aklan, Philippines.                                                                   ROGELYN  R. PENUELA                                                                                Affiant                                                                           SUBSCRIBED and SWORN to before me this November 25, 2011 in Jaro Iloilo City, Philippines.   Affiant personally appeared before me and exhibited to me her Philhealth I.D No. 11-11111111-1   to prove her identity