Republic of the Philippines)

City of San Pedro, Laguna ) S.,S.

AFFIDAVIT OF LOSS

2. That I used to put said ATM card in my wallet;

3. That sometimes on May 9, 2016, when I arrived home from work, I
discovered that said ATM card was no longer in my wallet;
4. That diligent effort to locate the same proved futile;
5. That in view thereof, I now desire and hereby request Landbank to
issue another ATM card in lieu of the lost one;
6. That I bind myself to save Landbank harmless from any loss or
damage that I may incur in connection with the issuance of a new ATM
card in lieu of the lost one;
7. That I am executing this affidavit to attest to the foregoing facts and
for any legal purpose it may serve.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of 2016.