Republic of the Philippines )

City of Dumaguete ) S.S.

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

AFFIDAVIT OF LOSS

I, LEO-NILLE N. IÑIGO, of legal age, Filipino, married and a resident of Lasola Drive,
Piapi, Dumaguete City, Negros Oriental, after having been sworn in accordance with law,
hereby deposes and states the following :

1. That I have an account with Land Bank of the Philippines under Payroll Account No.
3757-0201-05 and a holder of an ATM Card thereof;

2. That I have placed the said ATM card inside my wallet.

3. That last April 3, 2019, my wallet fell unknowingly from my pocket while I was in
Breadcamp, Daro, Dumaguete City.

4. That I tried to look for my wallet, but to no avail.

5. Hence, despite diligent search and efforts to locate the said wallet with my ATM
Card in it, I could not find the same such that I now honestly believe that it is now
lost beyond recovery;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support the application for the issuance of new one in lieu of the one which
was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of April 2019 in
Dumaguete City, Philippines.

LEO-NILLE N. IÑIGO
Affiant
UMID 006-0000-1897-3

SUBCRIBED AND SWORN TO before me this 8th day of April 2019 in Dumaguete
City, Philippines, affiant exhibiting to me her competent proof of identification.

WITNESS MY HAND AND SEAL.

Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2019.