REPUBLIC OF THE PHILIPPINES}

Tabuk City, Kalinga } S.S.

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

AFFIDAVIT OF LOSS

I, M., of legal age, Filipino citizen , single and with residence and postal
address at Brgy. Bulo, Tabuk City, Kalinga, having been duly sworn in
accordance with law, do hereby depose and state:

1. That I was issued an AUTOMATED MACHINE CARD(ATM card) by the

Landbank of the Philippines, Quezon City sometime in 2014;

2. That on or about 7:45 am of January 12, 2017, while on my way to the

office of the Provincial Fire Marshal located at Purok 6, Capitol Hills,
Bulanao, Tabuk City to render duty, I did not notice that my ATm was
missing ;

3. That my ATM was lost on the suspicion that I accidentally dropped it

somewhere while on the way to the office;

4. That diligent efforts were exerted to find the said ATM card but the
same proved futile and fruitless;

5. That the said ATM card was lost in the manner stated above and was
not confiscated nor cancelled by the issuing agency or other agencies for
violation of any of its terms and conditions, laws, rules and regulations;
and

4. That I am now executing this Affidavit to attest to the veracity of the

foregoing narration for securing a temporary blocking of my Landbank
account until a replacement of the said lost ATM card has been issued
and a change of Personal Identification Number(PIN) has been made;
and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 24 th day

September 2016, in the City of Tabuk, Philippines
Affiant
BFP ID NO. 14-1406546

SUBSCRIBED AND SWORN to before me this 24th day of September

in the City of Tabuk, Philippines by MANUEL B. SANO JR., who showed to
me his identification card stated aboved, and that he is the same person who
personally signed the foregoing affidavit before me and acknowledged that
he executed the same.