Republic of the Philippines S.

S
City of Manila

AFFIDAVIT OF LOSS

I, ALBERT C. ALCARAZ of legal age and residing at Cabiao, Nueva Ecija, after having
been duly sworn to according to law hereby depose and state that:

1. Sometime in December 2016, I was issued an ATM by the Landbank of the

Philippines;

2. On January 8, 2017, on my way to our office located at Manila, my wallet was pick-
pocketed which contains the said ATM and other important identification cards;

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

4. As such, I am executing this affidavit to attest to the foregoing facts and to support
the application for the issuance of a new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___day of January 2017 at
the City of Manila.

ALBERT C. ALCARAZ

Affiant

SUBCRIBED AND SWORN TO before me this ___ day of January 2017 in

Manila, Philippines, affiant exhibiting to me his valid proof of identification.

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2017.