REPUBLIC OF THE PHILIPPINES )

CITY OF LAOAG ) S. S.

AFFIDAVIT
I, _________________________ after having been duly sworn to in accordance with law, hereby depose
and state that:

I am a retired enlisted personnel of the Armed Forces of the Philippines (AFP) and who is now a pensioner
who has a maintaining account at the Land Bank of the Philippines (LBP), _______Branch, ________ City under
Savings Account No. _____________________;

I started withdrawing my pension on February 2019. However, the last time I withdrew with the bank on 20
March 2019 to be exact, I found out that my maintaining balance is FOUR THOUSAND THREE HUNDRED FIFTY
SIX AND 100/63 (Php4,356.63) PESOS only instead of TEN THOUSAND SIXTY NINE AND 100/63 (Php10,069.63)
PESOS. The unauthorized withdrawals were in the following manner:

DATE AMOUNT BRANCH

20 March 2019 Php488.00
20 March 2019 Php2,090.00
20 March 2019 Php3,135.00

Thus, I went inside the said bank to inquire about the said circumstance;

The bank informed me that it is because I made purchases on online store. However, I attest that in truth and
in fact, I never made purchase on any online store or shop using my account on the said bank.

Thereafter, the office-in-charge of the said bank called up the Customer Service and there I found out that
the online transaction is through LAZADA, an online store or shop, and I was also informed that the four (4) digit
number at the back of my ATM card might have been used by other people or scammer in making such online
purchases without my knowledge which caused me great prejudice and damage;

Also, to my honest recollection, when I filed for a loan at __________________ with office address at
___________________________________ through their Sales Agent __________________ of legal age, married,
Filipino citizen, and a resident of ______________________ who happened to be my friend and colleague for a long
time took a picture of my ATM card (both on the frontal and back portion thereof);

In view of the foregoing, this Affidavit is executed to affirm that I never purchased any parcel or item at
LAZADA or at any online store using my LBP Savings Account No.___________________ as mode of payment for
the same;

I attest to the veracity and truthfulness of the foregoing for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______________________

Philippines.

_____________________
Affiant