REPUBLIC OF THE 

PHILIPPINES)
CAUAYAN CITY, ISABELA                      ) S.S.
x-------------------------------------x
  

AFFIDAVIT OF LOSS 

         I, RANIEL G. CALATA, of legal age, Filipino, married and a resident of #34
Cabaruan, Cauayan City, Isabela, after having been duly sworn to in accordance with
law, depose and state:

1. That I am a holder of Automated Teller Machine (ATM) Card No. 4748 4410 7038 1087
duly issued in my favor by Landbank in the City of Ilagan;

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

3. That sometime on May 21, 2021, when I arrived home from work, I discovered that said
ATM card was no longer in my wallet;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request Landbank Cauayan City Branch to

issue another ATM card in lieu of the lost one;

6. That I bind myself to save Landbank Cauayan City Branch harmless from any loss or
damage that it may incur in connection with the issuance of a new ATM card in lieu of
the lost one;

7. That I am executing this affidavit to attest to the foregoing facts and for any legal purpose
it may serve.

         IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of May

2021 in Cauyan City, Isabela, Philippines.
          

RANIEL G. CALATA
Affiant
PRN ID No. A42190402164

SUBCRIBED AND SWORN TO before me this 24th day of May

2021 in Cauayan City, Isabela, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____;

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