REPUBLIC OF THE PHILIPPINES

PROVINCE OF BUKIDNON
CITY OF MALAYBALAY

)
) S.S
)

AFFIDAVIT OF LOSS
I, MARVELIN G. BARRIENTOS, of legal age, Filipino and a resident of
Zone 1, San Vicente, Sumilao, Bukdinon, after having been duly sworn to
according to law hereby depose and state:
1. That, I am an employee of D Asian Hills Bank, Inc. (A Rural Bank);
2. That, I am using this Smart Mobile Number 09299591871 as a
requirement with the Land Bank of the Philippines (LBP) for my Savings
Account with Account Number 0967 125 393;
3. That, sometime on September 18, 2015, my wallet was lost together
with my SIM Card and ATM Card while I was on board a multicab
vehicle on my way home;
4. That, upon knowledge that it was lost, I immediately exerted efforts to
locate the same but all efforts prove futile;
5. That, I am executing this affidavit in order to attest to the truth of the
foregoing circumstances and for the purpose of reporting the loss of
the said Smart Mobile Number 09299607547 and ATM Card Number
0967 125 393 for replacement thereof and for other legal purposes.
IN WITNESS WHEREOF, I have hereunto set my signature this
____________________, in Malaybalay City, Bukidnon, Philippines.

MARVELIN G. BARRIENTOS
Affiant
SUBSCRIBED AND SWORN to before me this ____________________,
affiant exhibiting to me his valid identification card as sufficient proof of his
identity, known to me as the same person who executed the foregoing
instrument. I hereby certify that I have examined the affiant and I am
satisfied that he understood the contents of his affidavit and has voluntarily
executed the same in his own free will.

Doc. No. ________

Page No. ________
Book No. ________
Series of 2015