Republic of the Philippines )

In the City of Baguio ) S.S.

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, Filipino, of legal age, single and with residence address at 381
Ancheta St., Catbangen, City of San Fernando, La Union after having been duly sworn to in
accordance with law, depose and say that:

1. I am the owner of the following ATM and Governmnt Issued ID

d. Land Bank of the Philippines ATM card

e. LTO Driver’s License No. A04-15-008297

3. On April 16, 2021 as I was in my office at the Department of Health and as I was about
to use the Land Bank ATM Card to withdraw cash I noticed that the ATM card is missing. Upon
checking all my identification cards it turned out that my LTO Driver’s License is also missing;

5. I exerted diligent efforts to locate the LAND BANK of the PHILIPPINES ATM card
and the LTO Driver’s License card but to no avail and I now consider it lost and beyond
recovery;

6. I am executing this affidavit to attest to the truth and veracity of all the foregoing facts
and to request from LTO-Baguio City and/or LTO- City of San Fernando, BDO and Land
Bank of the Philippines to replace and/or issue me a new Identification Cards and ATM
cards under my name and to relieve myself from any liability arising from fraudulent and illegal
use of the above-mentioned IDs and ATM cards.

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of May 2021 at
Baguio City, Philippines.

JUAN DELA CRUZ

Affiant
LTO DRIVER’S LICENSE No. ABS-123469

SUBSCRIBED AND SWORN before me this 13th day of May 2021 at Baguio City,
Philippines.