DUWA

DALAWA
I, JUAN DELA CRUZ, of legal age, married, Filipino citizen and a resident of Balili, La
Trinidad, Benguet, Philippines, after having been duly sworn to in accordance with law hereby
depose and state that:

1. I was issued an Automated Machine Card (ATM) which I kept on my ATM

Jacket/holder. TO wit:

LANDBANK of the PHILIPPINES ATM CARD

2. On February 03, 2023, after attending my class at Cordillera Career Development

College, Buyagan, La Trinidad, Benguet, I proceeded to Save More Km.4 La Trinidad,
Benguet to buy some personal things, I arrived at home at about 5:00 in the afternoon
when I notice that my ATM Card was missing which is inserted in my ATM
jacket/holder. I then started to locate it but I was not able to locate it at home.

3. Despite, diligent efforts made to locate my atm card jacket/holder, containing my ATM
Card I consider it loss and beyond the point of recovery because I might have
MISPLACE my ATM jacket/holder containing the above said card;

4. Finally, I am executing this affidavit to attest to the veracity and truthfulness of the
foregoing declaration and for the purpose of requesting for the re-issuance of the above
card, and for all legal intents and purposes this it may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this 4th day of February
2023.

JUAN DELA CRUZ

Affiant
PRC ID no.: 1234567; Baguio City

SUBSCRIBED AND SWORD TO BEFORE ME, this 4th day of February, 2023, at La