Bank Affidavit of Loss

AFFIDAVIT OF LOSS
☐Passbook ☐ATM Card ☐Certificate ☐Manager’s Check ☐ Others , please specify

___________________________________
I/We ( the “Affiant/s”), _________________________________________________________________________ married/ single,

of legal age, now residing at ________________________________________________________, after being duly sworn to in
accordance with the law, do hereby depose and state THAT:
1. I/We am/are accountholder/s of ________________________________________ Branch (the “Bank”):
2. I/We am/are the lawful holder/s of the __________________ (the “Subject”) with the following particulars:
_________________________________________________________________________________________________
3. I/We am/are the rightful owner/s of Subject and the funds covered thereby and the same was not assigned, conveyed or
ceded in favor of a third party;
4. Subject was lost/ stolen/ destroyed under the following circumstances:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5. Diligent efforts to retrieve/recover Subject proved futile;
6. I/We hereby agree jointly and severally to hold the BANK, its assigns, officers and employees free and harmless from any
liability and indemnify them for any loss or damage they may suffer as a consequence of the eventual delivery to me/ us
of the proceeds of said amount;
7. For lost / stolen / destroyed Manager’s Check, attached hereto and made an integral part hereof, is the supplementary
affidavit executed or caused to be executed by the Payee concerning the loss of physical possession of the Manager’s
Check;
8. This Affidavit is executed to attest to the truth of all the foregoing statements and to serve as basis for the following
request/s:
☐ Immediate closure of the above account and opening of a new one

☐ Issuance of a new passbook / card in lieu of the lost one under the same account number
☐ Renewal/roll-over/pre-termination of the TD Certificate/Placement Advice/Certificate of Participation/Confirmation of
Sale
☐ Cancellation of the manager’s check and issuance of a replacement check
☐ That the following changes be effected in all the records of the bank for the indicated Account/ Customer Number:
Account/Customer No.: __________________________
☐ Add ☐ Change ☐ Delete
From: _________________________________________
To :___________________________________________
☐Others Affidavit of Loss Passbook Notarization is required.
9. I /We am/are willing to testify in any court of justice to substantiate the truth and veracity of each and all of the
foregoing facts;
10. This Affidavit will serve as my / our unqualified undertaking and/or of the corporation or entity represented by me/us if
such is the case, to hold the Bank free and harmless from any loss or liability of whatever nature that it may incur or
stand to incur by reason of or as a consequence of acceding to my/our request including but not necessarily limited to the
obligation to honor in the hands of a holder in due course the Subject said to be lost, destroyed or stolen;
11. I /We undertake to surrender Subject to the Bank for proper disposition in the event that the same should be found and
located.
IN WITNESS WHEREOF, I / we have set my/our hands at this _____________ in ____________________ Philippines.
________________________________ ________________________________ ________________________________

Declarant Signature Over Printed Name Declarant Signature Over Printed Name Declarant Signature Over Printed Name
Signed in the Presence of:
________________________________ ________________________________
Witness Witness
SUBSCRIBED AND SWORN TO before me this _______________ in ____________________ Philippines, affiant/s

exhibited to me his/her/their respective proofs of identity as indicated below:
NAME ID TYPE AND NO. VALIDITY
WITNESS MY HAND AND SEAL.
Doc No. ______;

Page No. _____;
Book No. _____;
Series of 2021.
AFFIDAVIT OF LOSS

Bank Affidavit of Loss

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Bank Affidavit of Loss

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AFFIDAVIT OF LOSS

☐Passbook ☐ATM Card ☐Certificate ☐Manager’s Check ☐ Others , please specify

I/We ( the “Affiant/s”), _________________________________________________________________________ married/ single,

1. I/We am/are accountholder/s of ________________________________________ Branch (the “Bank”):

4. Subject was lost/ stolen/ destroyed under the following circumstances:

5. Diligent efforts to retrieve/recover Subject proved futile;

☐ Immediate closure of the above account and opening of a new one

Signed in the Presence of:

SUBSCRIBED AND SWORN TO before me this _ in ______ Philippines, affiant/s

NAME ID TYPE AND NO. VALIDITY

WITNESS MY HAND AND SEAL.

Doc No. ______;

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