Republic of the Philippines)

Medina, Misamis Oriental..) ss.

AFFIDAVIT OF LOSS

I, ROMMEL SABEJON TADIOS, of legal age, Filipino and with address

at P1 Bulwa Medina Misamis Oriental, after having been duly sworn to oath in
accordance with law do hereby depose and say;

1. That I am a holder of a Land Bank ATM Card which was issued to me

by the Land Bank of the Philippines. Sometime in the year 2018
2.
3. That I have recently discovered the said item is irretrievably lost and
can no longer be found despite diligent efforts to locate the same;

4. That I execute this affidavit attesting to the truth of the foregoing facts
and for whatever legal purposes that this affidavit may serve best.

IN WITNESS WHEREOF, I hereunto affix my signature this

___________________________ at Medina, Misamis Oriental.

ROMMEL SABEJON TADIOS

Affiant

SUBSCRIBED AND SWORN to before me this

____________________________ at Medina, Misamis Oriental by ROMMEL
SABEJON TADIOS, presenting to me his UMID ID No. CRN 0111-2424730 to
be the same person who executed the foregoing affidavit.

I HEREBY CERTIFY that I have personally examined the affiant and am

satisfied that he has read and understood his affidavit the contents of which he has
personal knowledge.