Republic of the Philippines )

City of Manila )

AFFIDAVIT OF LOSS

I, Ronaldo V Intia, of legal age, residing at 1751 Mindanao Ext., Sampaloc,

Manila, after having been sworn in accordance with law hereby depose and state:

1. That, I am a holder of Landbank Automated Teller Machine (ATM) card with

account number 0686114597;

2. That, I have recently discovered that the said ATM card was irretrievably lost
and can no longer be found despite diligent efforts to locate the same;

3. That, I execute this affidavit to attest to the truth of the foregoing facts and for
any legal purpose it may serve.
AFFIANT FURTHER SAYETH NAUGHT

Ronaldo V Intia
Affiant
SUBSCRIBED AND SWORN to before me this _____ of _________________
2022 at the City of Manila. The affiant exhibited to me his competent proof of identity as
indicated above.

Doc. No. _____________

Page No. _____________
Book No. _____________
Series of 2022