Republic of the Philippines

( Province of Davao del Sur )

(City of Davao ) S.S

AFFIDAVIT OF LOSS

I, MARITES C. KOH, of legal age, Filipino, single, with

residence at 1234 Apple Street, Monteritz Estates, Maa, Davao
City, Davao del Sur, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. I am an account holder of a Personal Savings Account

under the Landbank of the Philippines particularly the
Rizal Branch in Davao City;
2. The said account is under the Account No. 1234-56789;
3. On March 22, 2024 around 4:00 in the afternoon I was
about to withdraw money from a Landbank ATM machine
in San Pedro Street that I discovered I lost my wallet;
4. Efforts were exerted to locate the atm card, but in spite of
diligent search the said could not be found and the same
is now beyond recovery;
5. As such, I am executing this Affidavit of Loss to attest to
the truth and veracity of the foregoing and to support for
the issuance of an atm card or this affidavit shall serve
as such, in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand

this 22nd day of March 2024 at Davao City, Philippines.

MARITES C. KOH
AFFIANT
Driver’s License: L02-02-112345

SUBSCRIBED AND SWORN to before me this -

____________, in Davao City, Philippines, affiant exhibiting
before his competent proof of identification as described above
valid until April 22, 2026, issued by LTO Office Region XI in
Davao City.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2024.