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REPUBLIC OF THE PHILIPPINES)

CITY OF NAVOTAS) S.S.


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

AFFIDAVIT OF LOSS

I, CARLOS C. RABAGO, JR, of legal age, Filipino, single and a resident Of 51 San
Miguel St. San Jose Village, Bahay Toro/Project 8, Quezon City, after having been duly
sworn to in accordance with law, depose and state:
1. That I am a holder of Automated Teller Machine (ATM) SA 1596054818 duly issued in my
favor by Landbank. on August 10, 2015 in Navotas City;
2. That I used to put said ATM card in my wallet;
3. That sometime on August 20, 2013, when I arrived home from work, I discovered that
said ATM card and my wallet was no longer in my pocket;
4. That diligent effort to locate the same proved futile;
5. That in view thereof, I now desire and hereby request LBP to issue another ATM card in lieu
of the lost one;
6. That I bind myself to save LBP harmless from any loss or damage that it may incur in
connection with the issuance of a new ATM card in lieu of the lost one;
7. That I am executing this affidavit to attest to the foregoing facts and for any legal purpose it
may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 26th day of August
2015 in Navotas City, Metro Manila, Philippines.

CARLOS C. RABAGo, JR.


Affiant
PHL PASSPORT NO: EB0636259

SUBCRIBED AND SWORN TO before me this 27th day of August 2015 in Navotas City,
Metro Manila, Philippines, affiant exhibiting to me his valid proof of identification.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2015.