Republic of the Philippines )

Vigan City) ss.

AFFIDAVIT OF LOSS
I, Virginia Allagadan, of legal age, Filipino, and a resident of Mabilbila
Norte, Santa Ilocos Sur, after having been duly sworn to in accordance with law,
hereby depose and states;

1. That I lost my Land Bank ATM Card;

2. That I lost the said card when I was on my way to withdra, and suddenly
I lost control, and said ATM card fell out of my hand and went into a
canal;

3. That I tried to locate it but diligent efforts to locate the same failed and
said passport is now considered lost for all intents and purposes;

4. That said ATM Card was not confiscated by any officer of the law or the
officers of Landbank by reason of any violation of any law, ordinance, or
presidential decree or rules and regulation of said bank; and neither it was
offered as collateral for any loan;

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

6. That I attest the veracity of the foregoing information

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________at Vigan City

Virginia Allagadan
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of November

17, 2021 , affiant exhibited to me her ID No. ____________________and affiant
avows under penalty of law to the truth of the contents thereof.

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