Republic of the Philippines)

City of __________________ ) SS
Province of ______________ )

AFFIDAVIT OF LOSS

I, BYRON G. SAN PEDRO, of legal age, married and with

office address at 2nd floor City Hall Bldg. Brgy. Poblacion
1, City of San Jose Del Monte, Bulacan. After having been
duly sworn in accordance with law, hereby depose and say:

1. That, I maintained a Land Bank ATM Savings Account

with Account No. 3467055266;

2. That an ATM Card of the said account was issued to

me by LANDBANK Tungkong Mangga Branch;

3. Sometime, on January, 2016 I went to Tungkong Manga

Market and when I arrived home, I discovered that
the said ATM Card was missing and nowhere to be
found;

4. Notwithstanding diligent efforts to recover the

missing I.D, the same cannot be found and proved
futile and in vain;

5. That, I have reported the incident to the said Land

Bank branch as soon as the said card is lost;

6. That, I further execute this affidavit to attest

the truthfulness and veracity of the foregoing
facts and to secure replacement of the said ATM
Card and for whatever legal intent and purposes it
is deemed proper.

IN WITNESS WHEREOF, I hereunto affix my signature

below this 12th day of February 2016, at City of San Jose
Del Monte, Bulacan.

BYRON G. SAN PEDRO

Affiant

SUBSCRIBED AND SWORN to before me this 12TH day of

February 2016 at City of San Jose Del Monte, Bulacan;
Affiant exhibiting to me his Driver’s License No. N01-85-
017447 issued on September, 2015, issued at LTO QUEZON
CITY.

NOTARY PUBLIC

Doc. No. ____;

Page No. ____;
Book No. ____;
SERIES OF 2019