Republic of the Philippines )

San Carlos City, Pangasinan)) S.S

AFFIDAVIT OF LOSS

I, CRISTINE R. VARGAS, of legal age, married, Filipino citizen, and resident of Brgy.
Mapolopolo, Basista, Pangasinan, Philippines, after having been duly sworn in accordance with
the law, hereby depose and state that:

1. I am a holder of ATM CARD issued by the Land Bank of the Philippines San Carlos
City, Pangasinan;

2. On April 07, 2023, I discovered that the wallet containing the said ATM Card was
missing; and

3. Despite diligent effort to locate said card, the same proved to be futile up to the present
and presumed it lost and beyond recovery; and

4. I am executing this Affidavit of Loss to declare the truth of the above facts and to
substantiate the loss of said card and further, to request the proper authorities to issue
another one in my name.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________in

San Carlos City, Pangasinan, Philippines.

__________________________
CRISTINE R. VARGAS
Affiant
DSWD 4P’s ID N0.:015509001-6137-00167

SUBSCRIBED AND SWORN TO before me this ___________________ in San Carlos

City, Pangasinan, Philippines.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2023