REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, JOHN RAJAH ANARETA, Filipino, of legal age, residing at (Address), after

having been sworn in accordance with law hereby depose and state:

That I am the true and lawful owner of my Landbank ATM

Card No. ________________ under Savings Account No.
_______________________

That around 8:00 in the evening on __DATE______, I was

looking for my Landbank ATM Card but to my surprise, said
Landbank ATM Card could not found;

That I took pains to look for said Landbank ATM Card, but to
no avail;

That I am executing this affidavit to attest to the truth of the

foregoing and to request from Landbank of the Philippines-Elliptical
Road Branch for a new ATM Card.

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

_______________. 20___ at _________________________.

JOHN RAJAH ANARETA

SUBSCRIBED AND SWORN to before me, this ____ day of ______________,

20___ in ___________________ City, with affiant exhibiting his FPA Employee’s ID
No. _______________.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.