Republic of the Philippines )

City of Dumaguete ) S.S.

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

AFFIDAVIT OF LOSS

I, JON REY D. ABADA, of legal age, Filipino, married and a resident of Brgy.
Bolocboloc, Sibulan, 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 - Dumaguete Branch
under Savings Account No. 0297-1421-19 and a holder of an ATM Card thereof;

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

3. However, last May 25, 2019, while I was on my way from Dumaguete City to
Bolocboloc, Sibulan, Negros Oriental, my wallet which contained my Landbank
ATM Card was lost and nowhere to be found;

4. That 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;

5. 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 28th day of May 2019 in
Dumaguete City, Philippines.

JON REY D. ABADA

Affiant
UMID 021-1629-1571-5

SUBCRIBED AND SWORN TO before me this 28th day of May 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.