Republic of the Philippines)

City of Tacloban ) s.s.

Province of Leyte )
x-------------------------------x

AFFIDAVIT OF LOSS

I, HANNALEE JANE CINCO, of legal age, single, Filipino and resident of

Brgy. Picas, Tanauan, Leyte after having been duly sworn to in accordance with
law do hereby depose and say;

1. That I am a member of the Pantawid Pamilyang Pilipino Program (4Ps)

of Tanauan, Leyte;

2. That as such, I was issued LAND BANK ATM Card issued at Tanauan,
Leyte;

3. That above-mentioned ATM was kept in my possession and were

placed inside my wallet however, just recently when I was to make use of it I
noticed that the same could no longer be found believed to have been
dropped;

4. That I have made diligent efforts to locate above-mentioned ATM

Card and but the same have proven futile, hence, for all intent and legal
purposes I considered it lost and beyond recovery;

5. That in view thereof, I am now requesting the of LAND BANK, Tanauan

Branch, to issue another ATM Card in lieu of the lost one;

6. That I hereby hold the LAND BANK Tanauan Branch, free and harmless
from any loss or damage that it may incur by reason of or in connection with
the issuance of a new ATM Card;

IN WITNESS WHEREOF, I have hereunto affix my signature this 06 th day

of September 2022 at Tacloban City, Philippines.

HANNALEE JANE CINCO

Affiant

SUBSCRIBED AND SWORN to before me this 06 th day of September 2022

at Tacloban City, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2022