REPUBLIC OF THE PHILIPPINES)

CITY OF BATANGAS) S.S.

AFFIDAVIT OF LOSS
I, ______________________________, of legal age, married, Filipino and a resident
of __________________________, after being duly sworn to in accordance with law,
depose and state THAT:
1. I am the owner of an Autosave ATM Card with Account No.
_____________________ issued by the Land Bank of the Philippines;
2. I always kept my ATM Card along with other identification cards inside a pouch
bag;
3. Last May 8, 2022, we moved in from Mataas na Kahoy, Batangas to Lipa City,
Batangas;
4. When I was about to withdraw some cash last Friday, September 2, 2022, I found
out that the said pouch bag containing the said ATM Card was missing;
5. Despite diligent efforts exerted, I could not locate or recover the said ATM card,
and to the best of knowledge, the same is truly lost;
6. The said ATM card has never been confiscated by any officer of the law or the
issuing bank and never been pledged or used as a security to any obligations;
7. In the event that the said ATM card should hereafter be found or located, I
undertake to forward or surrender the same to the Land Bank of the Philippines for
appropriate disposal;
8. I am executing this Affidavit of Loss to attest to the truth of the foregoing
statements and for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ________________

at Batangas City, Philippines.

____________________________
Afffiant

SUBCRIBED AND SWORN TO before me this ____ day of __________________

at Batangas City, affiant exhibiting to me her ___________________

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2022.