Republic of the Philippines]

Calamba City, Laguna ] s.s.

AFFIDAVIT OF LOSS

I, NESTORIO PURI MERCADO, of legal age, Filipino, and with residence

address at No. 79 Manggahan Street, Pulo, San Antonio, Quezon after
having been sworn on accordance with law, depose and state that –

1. On 24 November 2019 after I withdrew money from an ATM Machine in

Calamba City, Laguna, I inserted my Land Bank ATM Card inside my
pocket. Thence, after a while, I took out my cellphone from the same
pocket. Inadvertently, I did not notice that the said ATM card
accidentally slipped out and fell somewhere along the way. It was only
on 27 November 2019 when I realized that my said ATM Card was
already missing and could not be located inspite of diligent search.

2. I searched in all possible places and containments for the said ATM card.
But inspite of diligent and painstaking efforts I was not able to locate or
recover the above-mentioned item. Hence, for all intents and purposes,
the said item is now deemed lost and beyond recovery.

3. I executed this affidavit to attest to the truth of the foregoing

declarations and to serve as supporting document in securing a
replacement for my lost ATM Card from Land Bank, Parian Branch,
Calamba City, Laguna.

IN WITNESS WHEREFORE, I hereto affixed my signature this 29

November 2019 in Calamba City, Laguna.

NESTORIO PURI MERCADO

Affiant

SUBSCRIBED AND SWORN to before me this 29 November 2019 by the

affiant with Driver’s License No. 012-08-006095 issued at LTO Calamba City
Office, valid until 2024/09/08.

Doc. No. _____; Atty. EMMANUEL E. SANDICHO

Page No._____; NOTARY PUBLIC
Book No._____; Until 21 December 2020, Commission No. 32-2019-C
Series of 2019 IBP O.R. No. 071222, 26 January 2019, IBP Laguna
PTR O.R. No. 6510269, 25 January 2019, Laguna
Roll No. 42246 admitted to practice, 09 May 1997
MCLE Compliance No. VI-0023440 dtd 04.11.2019
2nd Floor HK Bldg,. National Highway, Brgy. Halang
Calamba City, Laguna CALABARZON Philippines