MAYSA

ISA
Republic of the Philippines)
La Trinidad, Benguet) S.S.
AFFIDAVIT OF LOSS OF AUTOMATED MACHINE (ATM) CARD

I, JUAN DELA CRUZ, of legal age, married, Filipino citizen and a resident of Balili, La
Trinidad, Benguet, Philippines, after having been duly sworn to in accordance with law hereby
depose and state that:

1. I was issued an Automated Machine Card (ATM) which I kept on my ATM

Jacket/holder. TO wit:

LANDBANK of the PHILIPPINES ATM CARD

2. On February 03, 2023, after attending my class at Cordillera Career Development

College, Buyagan, La Trinidad, Benguet, I proceeded to Save More Km.4 La Trinidad,
Benguet to buy some personal things, I arrived at home at about 5:00 in the afternoon
when I notice that my ATM Card was missing which is inserted in my ATM
jacket/holder. I then started to locate it but I was not able to locate it at home.

3. Despite, diligent efforts made to locate my atm card jacket/holder, containing my ATM
Card I consider it loss and beyond the point of recovery because I might have
MISPLACE my ATM jacket/holder containing the above said card;

4. Finally, I am executing this affidavit to attest to the veracity and truthfulness of the
foregoing declaration and for the purpose of requesting for the re-issuance of the above
card, and for all legal intents and purposes this it may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this 4th day of February
2023.

JUAN DELA CRUZ

Affiant
PRC ID no.: 1234567; Baguio City

SUBSCRIBED AND SWORD TO BEFORE ME, this 4th day of February, 2023, at La
Trinidad, Benguet, Philippines. Affiant personally appeared known to me and to me known to
me to be the same person who executed the foregoing instrument and acknowledge to me that the
same is his free and voluntary act and deed.