Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, RIZALDY C. FERNANDEZ, Filipino, single, of legal age, resident of Brgy. Luta

Norte, Malvar , Batangas, Philippines, after having been sworn by law hereby depose and
state that:

1. I am the owner of an ATM Card issued by the landbank;

2. Sometime around May 23, 2024, in Brgy. Casay, San Francisco, Quezon around 4:30-
5:30pm, I lost the above ATM Card under the following circumstances;

3. despite diligent efforts exerted, I could not locate or recover the said ATM card, and to
the best of my knowledge, the same is truly lost;

4. The said ATM Card has not been confiscated by any officer of the law or the issuing
agency or office due to the violation of any law, statute, order, rule, or regulation;

5. If the lost ATM card should hereafter be found or located, I undertake to forward or
surrender the same to the company where I worked for appropriate disposal;

6. I am executing this affidavit to attest to the truth of the foregoing and to request the
issuance of a new ATM card to replace the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th of May, 2024, in Malvar,
Batangas, Philippines.

RIZALDY C. FERNANDEZ
Affiant
Issued ID: UMID
ID No. CRN: 0111-9924871-4

SUBSCRIBED AND SWORN to before me on this 30th day of May 2024, in Malvar,
Batangas Philippines.

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