Republic 

of the Philippines)
General Santos City ) S.S.
x ------------------------------------ x

AFFIDAVIT OF LOSS

I, JELLY G. AMPA, Filipino, of legal age, single, and a resident of E. Alegado,

Glan, Sarangani Province, Philippines, after being duly sworn in accordance with law,
depose and state:

1. That I am a member of the Indigenous People (IP) and I was issued a Landbank
Cash Card for the cash assistance grant by the government;

2. That sometime in the month of May this year, said cash card was lost;

3. That despite diligent search and effort to locate the said Cash Card, I could no
longer find the same; as such I believe that it is lost beyond recovery.

4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing

and to support my application for the issuance of new Cash Card, in lieu of the
one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________ in ___________________, Philippines.

JELLY G. AMPA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ___________________, in

______________, affiant exhibiting to me his Driver’s License as his competent proof of
Identity.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2022.