Republic of the Philippines)

City of Zamboanga
) S.S.
AFFIDAVIT OF LOSS
I, ELVIRA M. SUMICAD, of legal age, married and residing at La Union
Labason, Zamboanga del Norte , Philippines, after being duly, depose and say;
That I am the holder of a PAG-IBIG CASH CARD with the LAND BANK OF
THE PHILIPPINES (LANDBANK)
That on or about December 2014 my PAG-IBIG CASH CARD got lost in the
following manner;
a.) That I misplaced my brown envelop which contains my Pag-ibig Cash
Card and other personal and work related documents.
And its whereabouts cannot anymore be ascertained despite due and diligent
search made and undertaken.
That I now desire and hereby request LANDBANK for an issuance of a
new PAG-BIG CASH CARD in lieu of the one lost; that I am willing to
surrender the lost PAG-IBIG CASH CARD in the event that same could be
found and located; that I bind myself to hold LANDBANK free and harmless
from any loss or damage that may arise or it incur in connection with the
issuance of the new cash card: and each and all the facts herein stated are
true; and that I am willing to testify before any court of justice to substantiate
the truth of each and all above said facts.
IN WITNESS WHEREOF, I have hereunto affix my hand and signature at
City of Zamboanga, Philippines, on this 15th day of May 2015.

ELVIRA M. SUMICAD
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 15th day of May 2015,
in the City of Zamboanga, affiant personally appeared before me and exhibited
her Professional Identification Card No. 0838507, issued in Zamboanga City,
known to me to be the same person who executed the foregoing instrument,
and acknowledged that the same is his free act and deed.

Doc. No. ____________

Page No. ____________
Book No. ___________
Series of 2015