REPUBLIC OF THE PHILIPPINES

PROVINCE OF NORTHERN SAMAR

MUNICIPALITY OF CATARMAN

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)S.S.
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AFFIDAVIT OF LOSS

I, DANILO B. FEDELLAGA, of legal age and residing at Brgy.

Yakal, Catarman, Northern Samar, Philippines, after being sworn in
accordance with law, depose and say:
That I am a depositor of Land Bank of the Philippines-Catarman
Branch, and as such a Land Bank ATM Card was issued in my favor,
which unfortunately was lost or misplaced by me;
That despite of diligent search and efforts to locate the said ATM, I
could not find such, that I now believe that it is lost beyond recovery;
As such, I am executing this Affidavit of Loss to attest to the truth of
the foregoing and to support my application for the issuance of a new ATM,
in lieu of the one that was lost.
Affiant sayeth naught.
IN WITNESS WHEREOF, I have hereunto set my hand this ______
at Catarman, Northern Samar, Philippines.

DANILO B. FEDELLAGA
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant who is known to me to be
the same person who executed and personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of
the contents of said instrument.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2014.