Affidavit of Loss of ATM Captured by the Machine

Affidavit of Loss sample is provided here to guide in preparing the relevant document in case the ATM is captured by the machine.

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

AFFIDAVIT OF LOSS

I, MAKU LIMUTIN, of legal age, single, Filipino, and a resident of 1234 Quezon Ave., Dinagaan, Legazpi City, after having been duly sworn to, in accordance with law, do hereby depose and state that:

1. I was a holder of an Automated Teller Machine (ATM) card of Metrobank with number 13413414151;

1. On August 8, 20_____, at about 1:00 o’ clock in the afternoon, I was transacting with ATM machine at PBCom Tower, Makati City when I inadvertently forgot the card in the machine. Upon realizing that I was not able to retrieve the ATM card after my transaction, I returned to retrieve it but did not find the card in the machine.

1. I exerted efforts to locate it in every possible place but to no avail and suspected that the next person in line might have gotten it;

1. If I ever I will find it in the future I will inform the proper parties/authority about it;

1. I am executing this document to attest to the foregoing statements.

MAKU LIMUTIN
Affiant
ID: _______________

SUBSCRIBED AND SWORN to, this _______ day of August 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____