Republic of the Philippines )

City of _______________ ) S.S.

AFFIDAVIT OF DENIAL

I, ___________________(full name), Filipino, of legal age, single, and

a resident of __________________________(address), Philippines, after
being sworn to in accordance with law, hereby depose and state:

1. That I am the account holder of a Savings Account (Account No.

________________) with the Land Bank of the Philippines;

2. That on February 15, 2021, upon checking my Account via the mobile
app, I noticed that I was charged a total of Php 17,203.62 in three (3)
separate transactions detailed below:

1. POS INTL – Feb. 3, 2021 – 4,624.59

2. POS INTL – Feb. 3, 2021 – 4,880.95
3. POS INTL – Feb. 3, 2021 – 7,698.08

3. That the above transactions were not authorized by me;

4. That on the same date, I immediately transferred the remaining

balance from my account to another in order to prevent further
deduction;

5. That I am executing this Affidavit to attest to the truth of the foregoing

and in support of my claim of dispute against such unauthorized
charges against my account.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ 2021, in __________________, Philippines.

________________(full name)_____
Affiant

SUBSCRIBED AND SWORN to before me this _______________ 2021

in ______________, Affiant exhibiting to me her Driver’s License No.
_______________, issued on ___________ and valid until _______.

Doc No. _________;

Page No. ________;
Book No. ________;
Series of 2021.