REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF KALIBO ) S.S.

x-------------------------------------x

AFFIDAVIT OF LOSS

I, , of legal age, Filipino, single and a resident of (ADDRESS), after

having been duly sworn to in accordance with law, depose and state:

1. That I am a holder of Automated Teller Machine (ATM) Card No. duly issued
in my favor by Land Bank of the Philippines on July 2018 in LBP UP Diliman
EO, Diliman, Quezon City;

2. That I used to put said ATM card in my wallet;

3. That sometime on May 3, 2019, when I arrived home from work, I

discovered that said ATM card was no longer in my wallet;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request Land Bank of the
Philippines to issue another ATM card in lieu of the lost one;

6. That I bind myself to save Land Bank of the Philippines harmless from any
loss or damage that it may incur in connection with the issuance of a
new ATM card in lieu of the lost one;

7. That I am executing this affidavit to attest to the foregoing facts and for any
legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 5 th day of

May, 2019 in Kalibo, Aklan, Philippines.

Affiant
ID No.

SUBCRIBED AND SWORN TO before me this __ day of May,

2019 in Kalibo, Aklan, Philippines, affiant exhibiting to me his valid proof of
identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.