REPUBLIC OF THE PHILIPPINES )

CITY OF CAVITE ) S.S.

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

AFFIDAVIT OF LOSS

I, JOSEPH TAN, of legal age, Filipino, married, and a resident of Zulueta St.,
Brgy. 59, San Roque, Cavite City, after having been duly sworn to in accordance
with law, depose and state THAT:

1. I am the holder of a bank account in the Land Bank of the Philippines;

2. In connection with this, I am issued by the said bank a Land Bank ATM card
from Imus City Branch;

3. On or around the month of January 2018, the said ATM card was lost in my
possession;

4. Efforts were exerted to locate the said ATM Card, but in spite of diligent search,
it could not be found and the same is now beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application and release of a new Land Bank ATM
Card;

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

February, 2018 in Cavite City, Philippines.

JOSEPH TAN
Affiant

SUBCRIBED AND SWORN TO before me this ___ day of February in Cavite

City, Philippines, affiant exhibiting to me her competent evidence of identity by
way of ______________________ ID card with card number_______________ .

Doc. No. _____;

Page No. _____;
Book No. _____; Notary Public
Series of _____.