REPUBLIC OF THE PHILIPPINES )

_____________________________ ) SS.

AFFIDAVIT OF LOSS

I, SFO1 Salvador Villanueva Serrato Jr , Married, Filipino, of legal

age, and a resident of B335 L19 Birmingham Village, Pulo, Cabuyao
City, after having been duly sworn in accordance with law, hereby
depose and say:

1. That I am an owner of Land Bank ATM Card issued by Land

Bank of the Philippines;

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

3. That sometime on April 2020, as I was buying grocery from

the supermarket I discovered that my Land Bank ATM Card
was no longer in my wallet;

4. That diligent effort to locate and search in places where I

have been on that day, said ATM card was nowhere to be
found;

5. That said ATM card was not confiscated by the authorities

for any reason. Neither I violated any rules and regulations;

6. That I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of said ATM
Card from Land Bank of the Philippines.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

13th day of April 2020 at Calamba City, Philippines.

_________________________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN to before me this 13 th day of April

2020 at Calamba City, Affiant exhibiting to me his Bureau of Fire
Protection ID numbered S29066 valid until 10 May 2023 and issued
at Quezon City on 18 December 2019.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2020