REPUBLIC OF THE PHILIPPINES)

AFFIDAVIT OF LOSS

I, , under oath hereby depose and state:

That I am a holder of;

That I have been keeping said ATM Card in my wallet together with
other equally important identifications;

That my LANDBank ATM Card contained in my wallet was lost in my

possession and despite diligent effort exerted to locate said ATM card, all
efforts proved futile;

That up to the present I have not yet found the missing ATM Card and
is now considered lost and beyond recovery;

That said ATM Card was not transferred or confiscated but was merely
lost in my possession;

That I am now executing this affidavit to request the to issue another

ATM Card in lieu of the lost one with the same validity;

That I further execute this affidavit to attest to the veracity of the

above-stated facts and for whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature 27 th day

of November, 2015 in.

SUBSCRIBED AND SWORN to before me this 27 th day of November

2015 in.