Republic of the Philippines )

Puerto Princesa City ) S.S

AFFIDAVIT OF LOSS

I, SHEILLA PECORE JUNGCO, of legal age, Filipino, single and a resident of Acacia Road,
Barangay Tiniguiban, Puerto Princesa City, after having been duly sworn to in accordance
with law, depose and state THAT:

1. I am a holder of Automated Teller Machine (ATM) duly issued in my favor by Land

Bank, in 2015, Puerto Princesa City Branch;

2. I used to put said ATM card in my wallet, but sometime in January 2017, I discovered
that my ATM was no longer in my wallet;

3. I tried to look the said ATM card, despite diligent efforts exerted, I could no longer
locate, find or recover the said ATM card, and to the best of my knowledge, the same
is truly lost;

4. In view thereof, I now desire and hereby request Land Bank to issue another ATM
card in lieu of the lost one;

5. I am executing this affidavit to attest to the foregoing facts and for any legal purpose
it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this June 15, 2017 in Puerto
Princesa City.

SHEILLA PECORE JUNGCO/Affiant

PhilHealth No. 09-025470400-7

SUBCRIBED AND SWORN TO before me June 15, 2017 in Puerto Princesa City,
affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.