Republic of the Philippines

City of Cagayan de Oro

)
) S.S.

AFFIDAVIT of LOSS
I, LANA MAY SACOTE RACINES, of legal age, single, Filipino
and residential address at #33 Zone 1A, Iponan, Cagayan de Oro City after
having been sworn to in accordance with law hereby depose and say:
1. That I am a holder of a GSIS UMID E-Card, duly issued by Land Bank of
the Philippines, Velez Cagayan de Oro Branch;
2. That my GSIS UMID E-Card was my savings account with number
5106831701;
3. That on June 24, 2014 in the afternoon, I discovered that my GSIS UMID
E-Card was lost in my possession;
4. That despite diligent efforts to locate the same proved futile and said
GSIS UMID E-card is beyond recovery and is considered lost;
5. That I now desire and hereby request Land Bank of the Philippines to
issued a new GSIS UMID E-card in lieu of the one lost;
6. That I am willing to surrender the lost E-card in the event that same
could be found and located;
7. That I bind myself to hold Land Bank of the Philippines free and
harmless from any loss or damage that may arise or it may incur in
connection with the issuance of a new E-card; and
8. That each and all of the facts herein stated are true and that I am
willing to testify before any court of justice to substantiate the truth of
each and all of the above said facts.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 26 th
day of June 2014 in the City of Cagayan de Oro, Philippines.
LANA MAY SACOTE RACINES
Affiant
TIN 923-622-640-000

SUBSCRIBED AND SWORN to before me this 26 t h of June

2014 in the City of Cagayan de Oro, Philippines.
ATTY.
DOCDOCIL

EDITH

Notary
2014
D o c . N o. 3 8 2
01.24.11
Pa g e N o. 7 6
B o o k N o. X X I I
11.11.11.CDO
S e r i e s of 2 0 1 4
11.11.11.CDO

ABUT

Pu b l i c u n t i l D e c e m b e r 3 1 ,
102 Salvosa Building
C a p i s t r a n o - Lu n a S t s . , C a g d e O ro
M o b i l e N o. 0 9 1 6 . 8 4 6 8 . 1 1 1
MCLE
Compliance
N o. l l l - 0 0 1 9 8 8 5 ;
Ro l l o f At t o rn e y s N o. 5 6 4 6 3
P T R. N o. 2 1 0 2 2 6 6 A ;
I B P. N o. 8 3 2 6 6 3 ;