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Affidavit of Loss

This affidavit of loss details information about a lost bank document such as a savings passbook or certificate of time deposit. The affiant states that they are a depositor at a specific bank and have filed an insurance claim with the Philippine Deposit Insurance Corporation after the bank closed. The affiant further attests that the lost bank document cannot be found despite searching, and that they will be liable for any issues that arise from the representations in this affidavit. They also agree to refund any payments if the lost document is later found.

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347 views1 page

Affidavit of Loss

This affidavit of loss details information about a lost bank document such as a savings passbook or certificate of time deposit. The affiant states that they are a depositor at a specific bank and have filed an insurance claim with the Philippine Deposit Insurance Corporation after the bank closed. The affiant further attests that the lost bank document cannot be found despite searching, and that they will be liable for any issues that arise from the representations in this affidavit. They also agree to refund any payments if the lost document is later found.

Uploaded by

olongapo mpc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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A

Republic of the Philippines )


Municipality /City of ________________ ) S. S.
Province of ____________ )

AFFIDAVIT OF LOSS
I, ___________________________________, after having been duly sworn to in accordance
with law, do hereby depose and say that:

1. I am of legal age, single/married and a resident of


_________________________________________________;

2. I am a depositor/ agent of a depositor of the _________________________________;

3. I have filed claim/s for insured deposit with the Philippine Deposit Insurance
Corporation (PDIC);

4. The closed bank/ PDIC issued to me Savings Passbook/ Certificate of Time Deposit/
Checks/ Bank Statement/ Claim Stub No/s. ________________________;

5. The Savings Passbook/ Certificate of Time Deposit/ unused checks/ Bank Statement/
Claim Stub was _____________________________ (state circumstances surrounding the
absence of the document) and despite diligent search, said Savings Passbook/ Certificate of
Time Deposit/ unused checks/ Bank Statement/ Claim Stub can no longer be found;

6. I shall be held personally liable to any person, natural or juridical, that may be
prejudiced by my representations, in addition to other liabilities, civil or criminal, that
may arise therefrom; hereby releasing and discharging PDIC from any and all further
obligations in connection with this claim;

7. I undertake to refund PDIC the amount paid to me including interest thereon and
indemnify PDIC, the bank and/or third parties for any loss or damages occasioned by
such payment.

I am executing this affidavit to attest to the truth and veracity of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of


____________________ at _________________________________.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me in the Municipality/City of __________________ this ____


day of __________________ by the affiant, who has satisfactorily proven his/her identity to me through his/her
_______________________________________ issued on _________________ in _________________, that
he/she is the same person who personally signed the foregoing affidavit before me and acknowledged that he/she
executed the same.

Notary Public
Doc. No. ________ ;
Page No. ________ ;
Book No. ________ ;
Series of ________ .

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