Republic of the Philippines)

Province of Cavite ) S.S.

Municipality of Alfonso )

AFFIDAVIT OF LOSS
I, __________________________________, Filipino, of legal age,
single and with residence at __________________________, after being duly
sworn to in accordance with law, hereby depose and state:

1. On November 9, 2018, while I was riding a bus on my way home, I accidentally

dropped my wallet without my knowledge;

2. Included inside my wallet is my Automated Teller Machine Card (ATM Card)

issued by Land Bank of the Philippines (Tagaytay City- Branch);

3. Despite diligent search and efforts to recover the said card holder the same can
no longer be located;

4. I am executing this affidavit not for any unlawful purpose but only for the
purpose of application for replacement of the said ATM Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of March 2018
at Province of Cavite, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this 1st day of March 2019

_______________ Cavite. Affiant exhibiting to me his
_____________________

WITNESS MY HAND AND SEAL.

Doc. No. ;
Page No. ;
Book No. L ;
Series of 2019.