Republic of the Philippines)

Province of Bulacan )
City of Malolos )
x ------------------------------ x

AFFIDAVIT OF LOSS

I, FLORIZELLE M. CHICO, of legal age, Filipino and a resident of No. 82 Iba

Oeste, Calumpit, Bulacan, under oath, depose and say:

1. That I am the lawful holder of an ATM CARD from LAND BANK OF THE
PHILIPPINES with Account Number ______________;

2. That the said ATM CARD was misplaced or left somewhere which I
cannot recall despite diligent efforts to locate it, I cannot find it anymore;

3. That the lost ATM DEBIT CARD was not borrowed by anyone from me;

4. That I execute this affidavit to vouch for the truth of the foregoing and for all
other legal intents and purposes it may serve.

IN WITNESS, WHEREOF, I have hereunto signed my name on this instrument

on this 13th day of November, 2019 in the City of Malolos, Province of Bulacan.

FLORIZELLE M. CHICO
Affiant

PERSONALLY, APPEARED BEFORE ME, a Notary Public for and in the

Province of Bulacan, on this 13th day of November, 2019, who subscribed and sworn to
the foregoing document and who avows under the PENALTY OF LAW to the truth of
its contents.

I hereby certify that the affiant has been identified by the undersigned Notary
Public through Competent Evidence of Identity: Employee ID No. 1011-JO-30.

WITNESS MY HAND AND SEAL.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.