REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x-------------------------------------x

AFFIDAVIT OF LOSS

I, GERARDO L. TAN, of legal age, Filipino, single and a resident of 2222 Washington Street, Pio del Pilar, Makati City, after having been duly sworn to in accordance with law, depose and state:

1. That I am a holder of Automated Teller Machine (ATM) Card No. 123456789 duly issued in my favor by Banco de Oro Unibank, Inc. on January 12, 2010 in Makati City;

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

3. That sometime on July 20, 2013, when I arrived home from work, 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 BDO to issue another ATM card in lieu of the lost one;

6. That I bind myself to save BDO harmless from any loss or damage that it may incur in connection with the 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 have hereunto set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

Voter's ID No. _________________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of __________________, by ___________________ with Passport No.________________ issued on __________________ at _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;