Republic of the Philippines )

City of Ormoc ) S.S.

AFFIDAVIT OF LOSS

I, BENJAMIN S. PONGOS, JR., of legal age, Filipino, single and with

residence at 611 Bonifacio Extension, District 18, Ormoc City, Leyte, after
having been sworn to oath in accordance with law, hereby depose and state:

1. That I am a holder of the LANDBANK ATM card with account

number 0957051278 issued by Landbank Ormoc Branch;

2. That sometime last week, when I arrived home from work I

discovered that my LANDBANK ATM card was no longer in my
wallet where I used to place it;

3. That despite diligent search and efforts to locate my ATM Card, I

could not find the same such that I now believe that it is now
lost beyond recovery;

4. Said ATM Card was not confiscated by any officer of the law or
the officers of LANDBANK by reason of any violation of any law,
ordinance, presidential decree or rules and regulation of said
bank; and neither was it offered as collateral for any loan;

5. That I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of my
LANDBANK ATM card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day

of June 2017 at Ormoc City, Leyte.

BENJAMIN S. PONGOS, JR.

Affiant

Subscribed and sworn to before me this ___ day of June 2017 at Ormoc
City, Leyte. Affiant exhibiting to me his
_____________________________________________________ as competent proof of
his identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.