REPUBLIC OF THE PHILIPPINES)

PROVINCE OF XXX) S.S.

AFFIDAVIT OF LOSS
I, XXX, of legal age and a resident of XXX, after having
been sworn to in accordance with law, hereby depose and
state:

1. That few years ago, I was a holder Land Bank of the

Philippines (LBP) ATM Card - Masbate City Branch so
that the loan proceeds from PAG-IBIG would be
deposited;

2. That after I withdrew the proceeds from the said bank ,

I placed my ATM card inside my wallet;

3. That unknowingly, I seated on my wallet and ultimately

my ATM Card which resulted to the mutilation of the
same;

4. That since it could not be used, I threw the said card

somewhere, since I have finished my transaction with
LBP and PAG-IBIG;

5. That recently I discovered that the said bank account

is still active and can still be used for my next
transaction with PAGIBIG;

6. That in view of the foregoing the said card is

considered as lost and destroyed and could not be
retrieved;

7. That I execute this affidavit to attest to the truth to

of the foregoing and for the purpose of re-issuance of
a new LBP ATM Card.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 8th day of June 2021 in XXXX.

XXXX
Affiant

SUBSCRIBED AND SWORN to before me this 8th day of June

2021 in XXXX, Philippines, affiant exhibiting to me his
Driver’s License No:XXXX, valid until 2023/06/01, issued by
LTO.