Republic of the Philippines)

Province of Tarlac ) S.C.

AFFIDAVIT OF LOSS

I, RICARDO M. ANTALAN, of legal age, married, Filipino and a resident of Brgy. San
Francisco, Victoria, Tarlac after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am a holder of a Landbank ATM Card;

2. That I usually placed the said ATM inside my wallet for safekeeping;

3. That I misplaced my ATM and it was nowhere to be found;

4. That I continue to search for several days and exerted all my effort to find the same
but still could not find it.

5. That after exhausting all possible means to locate it, it is already beyond my control
to find the lost ATM.

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

statements and inform the proper authority concerned about said lost ATM and for
whatever legal purpose this affidavit may duly serve.

IN WITNESS whereof, I have hereunto set my hand this 19th day of April 2022 in
Victoria, Tarlac Philippines.

RICARDO M. ANTALAN
Affiant

SUBSCRIBED AND SWORN to before me this 19th day of April 2022 in Victoria,
Tarlac Philippines, who exhibited to me his Competent Evidence of Identity.

Doc. No.
Page No.
Book No. VI
Series of 2022.