REPUBLIC OF THE PHILIPPINES)

C I T Y OF I L O I L O )ss.

AFFIDAVIT OF LOSS

I, HAZEL S. GERMANO, of legal age, Filipino, single and a resident of Barangay

Bansag, Lambunao, Iloilo, Philippines, after having been sworn depose and state THAT:

1. I am a student of Iloilo Science and Technology University (ISAT-U) with the course
of B.S. Civil Engineering and at the same time a DOST scholar;

2. Being a DOST scholar I am provided with semestral allowance/stipend through my

ATM account with Land Bank of the Philippines with number 394607131 04;

3. Mid-afternoon of February 01, 2023, I went to Iloilo Divisoria Novelty Shop to buy
for some personal items located within the downtown area of Iloilo City. As I was
about to pay for my purchases at the counter then I discovered that my wallet
containing my ATM card, PSA National ID and some cash was nowhere to be found in
my bag;

4. I exerted diligent effort to locate said wallet with the rest of its contents but the same
went to no avail which I surmised I was a victim of pickpocket while shopping at said
establishment. Thus, I considered it for all intents and purposes of the law to be
forever lost and beyond recovery; and

5. I executed this affidavit of loss in order to attest the truth of the foregoing and to
support my claim for the loss of said Land Bank of the Philippines ATM card and PSA
National ID as a requisite for the issuance of a replacement card and for whatever
legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this __________________,

in the City of Iloilo, Philippines.

HAZEL S. GERMANO
Affiant
GIID: ISAT-U 2021-5722-A

SUBSCRIBED AND SWORN to before me this _________________, in the City of

Iloilo, Philippines, affiant having exhibited to me her valid identification card written below her
name as proof of identity.

Doc. No. ____;

Page No. ____;
Book No.____;
Series of 2023.