REPUBLIC OF THE PHILIPPINES )

PROVINCE OF TARLAC )
MUNICIPALITY OF CONCECPCION ) S.S

AFFIDAVIT OF LOSS

I, EDNA SESE CANLAS, of legal age, Filipino, married, and a resident of

Brgy. Green Village, Concepcion, Tarlac, after having been sworn to in
accordance with law, hereby depose and state –

1. I was issued a Pantawid Pamilyang Pilipino Program (4P’s) ATM

Card by the Land Bank of the Philippines, the account number of which I could
not remember;

2. Sometime in April 2023, while I was rummaging through my

belongings, I noticed that the said ATM Card is missing;

3. Despite diligent search and efforts to locate the said ATM Card, I
could not find the same. As such, I believe that it is now lost beyond recovery;

4. The said ATM card has not been confiscated by any officer of the
law or the issuing bank due to the violation of any law, statute, order, rule or
regulation;

5. In the event that the lost ATM card should thereafter be found or
located, I undertake to forward or surrender to Land Bank of the Philippines for
appropriate disposal;

6. I am executing this affidavit to attest to the truth of the foregoing

facts, in support of my application for the issuance of a new ATM Card, and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________ at ______________________.

EDNA SESE CANLAS

Affiant

SUBSCRIBED AND SWORN to before me this _______________________

at ______________________. Affiant exhibited to me her ______________________
no.__________________________ as her competent evidence of her identity.

Doc No. _____;

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