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REPUBLIC OF THE PHILIPPINES)

PROVINCE OF DAVAO DEL NORTE) S.S

CITY OF TAGUM)

AFFIDAVIT OF LOSS OF ATM CARD

I, JUAN T. DELA CRUZ, Filipino, of legal age and a resident of Brgy. Magugpo South, Tagum City, after
having duly sworn in accordance with law, hereby depose and say that:

1. I am a holder of Tagum Coop ATM Card with account number 100950763738 issued by Tagum
Coop, Tagum Branch.
2. I used to put said ATM card in my wallet.
3. Sometime on January 20, 2023, when I arrived home from work, I discovered that my ATM card
was no longer in my wallet.
4. Diligent effort to locate the same had proved futile.
5. I am executing this affidavit to attest to the truith of the foregoing facts and to request
replacement of my Tagum Coop ATM card.

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