AFFIDAVIT OF LOSS

I, XXXXXXX, of legal age, Filipino, married, and resident of

XXXXXXX, after being duly sworn according to law, hereby depose and state that:

1. I am an account holder of the Landbank of the Philippines – XXXXX Branch

with account number XXXXXXX and was issued an ATM with card number
XXXXXXX.

2. Sometime in November 21, 2022, I lost the above

ATM while doing some grocery shopping in SM XXXXXX in XXXXXXX.

3. Despite diligent efforts exerted, I could no longer locate, find or recover the
said ATM, and to the best of my knowledge, the same is truly lost.

4. I am executing this Affidavit to attest to the truth of the foregoing statements

and to request the issuance of a new ATM in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 28 th day of

November,
2022 in Quezon City.

XXXXXXXX
Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant

exhibited to me her Competent Evidence of Identity by way of SSS ID XXXXXXXX.

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