AFFIDAVIT OF LOSS

□ Passbook ATM Card □ Certificate □ Manager’s Check □ others, please specify _______________
I/We (the “Affiant/s”), ARNEL ESCABARTE ESCABOSA,
married/ single, of legal age, now residing at Anibongan, Maco, Compostela Valley, Philippines,
after being duly sworn to in accordance with the law, do hereby depose and state THAT:

1. I/We am/are accountholder/s of One Network Bank (ONB) – Quirino, Panabo City Branch (the “Bank”);
2. I/We am/are the lawful holder/s of an ATM card (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:
Recently, I have discovered that my wallet, which contained my aforementioned ATM card, was missing from my
pocket. I believed that the same was unlawfully taken by an unidentified person/s while I was within the vicinity of
Brgy. Tibal-og, Sto. Tomas, Davao del Norte, Philippines;
5. Diligent efforts to retrieve/recover Subject proved futile;
6. I/We hereby agree jointly and severally to hold One Network 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 the 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

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 honour in the
hands of a holder in due course the Subject said to be lost, destroyed or stolen;
11. I/We undertaking 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 Santo Tomas, Davao del Norte, Philippines, this October 14, 2019.

ARNEL E. ESCABOSA
Affiant

Signed in the Presence of:

IANLI V. QUIÑANOLA SHIENA MAE R. DUMANACAL

SUBSCRIBED AND SWORN TO before me this October 14, 2019 in Santo Tomas, Davao del Norte, Philippines , affiant/s
exhibited to me his/her/their _________________________ issued at _________________________ on
______________________ and Community Tax Certificate No. _______________________ issued in
__________________ on __________________.

Doc. No. 230;

Page No. 46;
Book No. 240;
Series of 2019.

Memo effective January 23, 2018