REPUBLIC OF THE PHILIPPINES}

DONE: IN THE PROVINCE OF LA TRINIDAD } S.S.

x ------------------------------------------- x

AFFIDAVIT OF LOSS OF ATM CARD

I, SHENY G. MADRIAGA, of legal age, Filipino citizen, single and with residence and postal
address at Richview Square, Bakakeng, Baguio City, having been duly sworn in accordance with law, do
hereby depose and state:

1. That I was issued by the LANDBANK OF THE PHILIPPINES an ATM Card issued sometime on
January 2020 which will expire on October 2029 with account number 3246 0931 63;

2. That yesterday, October 26, 2020 I went to a computer shop in Porta Vaga to print some
documents. I paid using cash. When I got home I discovered that my LANDBANK ATM Card was
no longer in my wallet;

3. That diligent efforts were exerted to recover the said ATM CARD but the same proved futile and
fruitless;

4. That the said ATM Card was lost in the manner stated above and was not confiscated nor
cancelled by the issuing bank or other agencies for violation of any of its terms and conditions,
laws, rules and regulations;

5. That I am now executing this affidavit to attest to the veracity of the foregoing narration for
securing a replacement of the said lost passport and for all legal intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 27th day of October 2020, in La
Trinidad, Benguet, Philippines.

_______________________
SHENY G. MADRIAGA
Affiant

SUBSCRIBED AND SWORN to before me, in La Trinidad, Benguet, Philippines, this 27th day of
October 2020, by Sheny G. Madriaga, who has satisfactorily proven his identity to me through his Non-
Professional Driver’s License No. A06-20-006314 valid until March 3, 2025, and that she is the same
person who personally signed the foregoing affidavit before me and acknowledged that she executed the
same.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No.: __;
Page No.: __; ATTY. DENESS LOUISE G. CAOILI-MARCELO
Book No.: __: Notary Public for and in the Province of Benguet
Util December 31, 2021; NC Pro. No. 201-NC-0502
Series of 2020. Roll No. 74678; July 15, 2020; Manila
PTR No. 6789422; 07-20-2020; Benguet Province
IBP No. 127880; 08/27/2020; Pasig City
MCLE Compliance No. (Admitted to the Bar on June 18, 2019)
Suite 201-A Pine Valley Plaza, JB-012, Km. 4, La Trinidad,
Benguet
Phone Number: (074) 619 3530
Email address: denesscaoilimarcelo@yahoo.com