Republic of the Philippines))

Municipality of Silang, Cavite)) s.s.

x-----------------------------------------x

AFFIDAVIT OF LOSS

I, KAMILLE GRETCHE Z. CUEVAS, Filipino citizen, of legal age, presently residing at

038 Banaybanay, Amadeo, Cavite after having been duly sworn to in accordance with the
law, do hereby depose and say:
1. That I am a member of Philippine National Police stationed at the
Municipality of Silang, Province of Cavite;
2. As a government employee, I receive my salary through Landbank of the
Philippines and collect the cash from automated teller machine (ATM).
3. That sometime last week, I found out that the ATM card issued to me by
Landbank of the Philippines with payroll account name Kamille Gretche Z.
Cuevas had been missing and I could not locate it;
4. That I exerted diligent effort in locating the said lost ATM card, but to no
avail;
5. That I hereby declare that the said ATM card is lost and beyond recovery;
6. That I am executing this affidavit to attest to the veracity of the foregoing
facts for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I hereby affix my signature this __________ day of _____________

in the year _____________ in ___________________________________.

KAMILLE GRETCHE Z. CUEVAS

Affiant

SUBSCRIBED AND SWORN to before me this ________ day of ________________ in the

year _________ affiant having exhibited to me her _________________________ with number
__________________________ issued in_____________________________ on __________________________________
and valid until _______________________________ at _____________________________________.

Doc. No.: _______________________

Page No.: _______________________
Book No.: _______________________
Series of: _______________________