Republic of the Philippines )

Province of )
City of )s.s
x-------------------------------x

AFFIDAVIT OF LOSS

I, __________, 33 years old, Filipino, married, and a resident of

___________________, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and state THAT:

1. I am the same person whose circumstances stated above;

2. I am a holder of a LandBank-ATM Card issued by the LandBank of

the Philippines;

3. Sometime on 03 October 2019, when I was strolling inside the Mall,

I noticed that I my wallet placed inside my bag where I put my atm
card was missing;

4. Upon discovery of the same, I decided to look for it and went back
to where I have been and gone through the Mall;

5. Despite diligent search and effort to retrieve my wallet, I could not

find the same that I now believe that it is beyond recovery;

6. As such, I am executing this affidavit to attest of the truth of the

foregoing statement and to support my application for issuance of
new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I hereunto set my hand this

______________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____________

Philippines, affiant exhibiting to me her competent evidence of identity
written below her name and signature.