Republic of the Philippines )

Dumaguete City ) S.S.

x------------------------------------------------x

AFFIDAVIT OF LOSS
I, VIOLETA LOPINA DAGANDAN, of legal age, Filipino, widow, and a resident of Sta.
Agueda, Pamplona, Negros Oriental, after having been duly sworn to in accordance with law, do
hereby depose and state THAT:

1. I was issued a Land Bank ATM Card for Account Number 00001736437771;

2. On February 1, 2019, I noticed that the said ATM Card was missing and was probably
misplaced;

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

4. Such ATM Card was not confiscated by any government authority;

5. As such, I am executing this Affidavit of Loss to attest, confirm and declare the truth of
the foregoing, to support my request to have the amount left in the said ATM Card be
transferred to my new ATM Card, and for whatever legal purposes this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of February, 2020 at
Dumaguete City, Philippines.

VIOLETA LOPINA DAGANDAN

Affiant
Identification Card: Postal ID
Identification Card Number: 6112033

ACKNOWLEDGMENT
SUBSCRIBED and SWORN to before me this 10th day of February, 2020, personally
appeared Affiant who is known to me and identified by me by competent evidence of identity in
accordance with the 2004 Rules on Notarial Practice, who exhibited to me the above
identification card, who executed this foregoing Affidavit of Loss and acknowledged that the
same is her free and voluntary act and deed. This instrument consisting of one page, including
this page whereon this Acknowledgement is written has been signed by Affiant.

IN WITNESS WHEREOF, I have hereunto affixed my signature and notarial seal this
10th day of February, 2020 in Dumaguete City, Philippines.

Doc. No._____
Page No.____
Book No. ____
Series 2020.