REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF xxxxx : S.S.

PROVINCE OF xxxx )

AFFIDAVIT OF LOSS

I, xxxx, of legal age, married, Filipino citizen and a resident of

Palo, after being duly sworn to in accordance with law, hereby depose
and state:

1. That I am a holder of LANDBANK ATM Savings with

account number xxxxx;

2. That said atm was issued by Landbank- xxxxx Branch;

3. That today I discovered that said ATM was missing, and

that despite diligent efforts exerted for the purpose of
locating and recovering such, all said efforts proved futile
as I failed to find and recover said document to the
present;

4. That I have a well-founded belief that said ATM card is no

longer recoverable and forever lost;

5. That I am executing this Affidavit for the purpose of

attesting to the truth of the foregoing statement, and also
for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 6th day of January at xxxxxe.

xxxxAffiant
PRC No.0005863

SUBSCRIBED AND SWORN to before me a Notary Public for and

in the Province of xxxx this 6th day of January at xxxxx.

Doc. No._____;
Page No._____;
Book No. ___;
Series of 2020.