REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF IBA ) S.S.

PROVINCE OF ZAMBALES )

AFFIDAVIT OF LOSS

I, MICHAEL DAN SEVILLA, Filipino, of legal age, and with address at

Palauig, Zambales, being first duly sworn in accordance with law, depose and
state that:

1. I am a peso savings account holder in Land Bank of the Philippines

with account number 1126241239, Iba branch with ATM card;

2. However, last week I noticed that my ATM was missing from my

wallet where it was kept;

3. I searched high and low for my ATM card but still could not locate the
same;

4. I hereby expressly state that the aforementioned ATM card can now
be considered, for all legal intents and purposes, lost beyond recovery;
and

5. I am executing this affidavit to attest to the truth and veracity of the

foregoing facts.

MICHAEL DAN SEVILLA

Affiant

SUBSCRIBED AND SWORN to before me this ________________ at Iba,

Zambales. Affiant exhibited to me his Driver’s License ID No: CO9-14-002905.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.