AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES

_________________) S.S.

I, Nicanor U. Peaverde, Filipino, of legal age, residing at Cacawan,

Pinamalayan, Oriental Mindoro, after having been sworn in accordance with law hereby
depose and state:
That I am the holder of Land Bank of Philippines (LPB) ATM Card Number
3625-0002-37 issued at LBP Roxas, Oriental Mindoro pertaining to said ATM Card has
been lost last May 7, 2016 at Buendia, Metro Manila and could not be found.
That I exerted all efforts to look for said ATM Card, but to no avail;
That I am executing this affidavit to attest to the truth of the foregoing facts and to
facilitate processing of my request for replacement.
IN WITNESS WHEREOF, I have hereunto set my hand this 11th day of May at Bansud,
Oriental Mindoro.

NICANOR U. PEAVERDE
NAME
SUBSCRIBED AND SWORN to before me, this 11th day of May, 2016, at Poblacion, Bansud,
Oriental Mindoro, with affiant exhibiting his CTC No. 14390594 issued on January 27, 2016 at
Pinamalayan, Oriental Mindoro.

NOTARY PUBLIC
Until December 31, 20 _____
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Series of 20 ______.