REPUBLIC OF THE PHILIPPINES )

) S.S.
)
X - - - - - - - - - - - - - - - - - - - -- - - - - X

AFFIDAVIT OF LOSS

I, --------------, of legal age, Filipino, widow, and a resident of_______________,

Philippines, after having been duly sworn in accordance with law, hereby depose and
state:

1. I am the holder of an ATM Card issued by the Land Bank of the Philippines
(LBP);

2. That on April 11, 2018, I lost my wallet at ______________ while I was

attending to a transaction;

3. That I exerted efforts to retrieve my AUB ATM Card, but it proved to be

fruitless;

4. That I lost my ATM Card through accident and with the exercise of diligence
of a reasonable and prudent person exercising care over her things and
circumstances;

5. That I am executing this affidavit in order to attest to the veracity of the

foregoing facts and for whatever legal purpose this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

at ______________________, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me, this _______________ by affiant who

exhibited to me her ___________________ issued at_______________, Philippines as
her Competent Evidence of Identity (CEI) in accordance with the 2004 Rules on Notarial
Practice. I HEREBY CERTIFY THAT SHE UNDERSTOOD THE CONTENTS OF THIS
AFFIDAVIT AND THAT THE SAME IS TRUE AND CORRECT ACCORDING TO HER OWN
KNOWLEDGE AND BASED ON AUTHENTIC RECORDS.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.