REPUBLIC OF THE PHILIPPINES}

CITY OF GENERAL SANTOS } S.S.

X---------------------------------------------X

AFFIDAVIT OF LOSS

I, RAY ORACION LLOREN, of legal age, Filipino, married, and a

resident of #64 First Road Mentors Village, RH-XII, Cotabato City, under oath,
hereby depose and say:

1. That I have an account with LANDBANK Koronadal City Branch

located at Koronadal City, with Current Account No. 0755-
0280-22;

2. That I was issued an ATM card by the said bank;

3. That the said atm card was lost on December 3, 2021 while
strolling at Alunan Ave. Koronadal City;

4. That I was unable to find the said ATM Card despite diligent efforts
exerted to locate the same and never materialized up to the present
time;

5. That I am executing this affidavit for the replacement/re-issuance of

a new ATM Card; and

6. That I am executing this affidavit to attest to the truth of all the

foregoing, to inform all offices concerned, and for whatever legal
purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this December

13, 2021 at General Santos City, Philippines.

RAY ORACION LLOREN

Affiant

SUBSCRIBED AND SWORN to before me this December 13, 2021 at

General Santos City, with his DepEd ID No. 64114511, issued at General
Santos City.

Doc No. ATTY. IRELAN B. DITCHON

Page No. PNC 20-47 2/13/20
Book No. Roll No. 65657
Series of PTR No. 9506931 1/14/19
IBP Mo. 1010 11/15/19
2/F Velasque Bldg. G.S.C.