AFFIDAVIT OF LOSS

I, Joselito V. Bustillo, Filipino, of legal age, residing at 125 Villanueva Street, Dalandanan,
Valenzuela City, after having been sworn to in accordance with law hereby depose and state:

That I am the holder of the Security Bank ATM card with account no 0111 334 903 310;

That around 5:30 p.m. of March 24, 2015, during rush hour in Light Rail Transit 1 (LRT1), my
wallet was picked pocket from my bag containing the aforementioned ATM Card;

That I am executing this affidavit to attest to the truth of the foregoing facts for the purpose of
replacement of the said ATM Card.

IN WITNESS WHEREOF, I have hereunto set my hand on this _______day of March 2015 in
the City of Manila.

JOSELITO V. BUSTILLO
Affiant

SUBSCRIBED AND SWORN to before me in the City of Manila this _____ day of March 2015
by the affiant, who has satisfactory proven to me through his SSS No. 33-1482-005-4 issued at
____SSS , that he is the same person who personally signed this affidavit before me and
acknowledged that he executed the same.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2015.