REPUBLIC OF THE PHILIPPINES

PROVINCE OF BUKIDNON
CITY OF MALAYBALAY

)
) S.S
)

AFFIDAVIT OF LOSS
I, TEONILO P. TUBELLEJA, of legal age, Filipino and a resident of
Poblacion Laguindingan, Mlisamis Oriental, after having been duly sworn to
according to law hereby depose and state:
1. That, I am an employee of D Asian Hills Bank, Inc. as a company
driver;
2. That, I am using this Smart Mobile Number 09299607547 as a
requirement for my Savings Account with Land Bank of the Philippines
(LBP);
3. That, sometime on April 20, 2015, while I am attending guests and
preparing food for our town fiesta, my cellphone was lost together with
the attached SIM card;
4. That, upon knowledge that it was lost, I immediately exerted efforts to
locate the same but all efforts prove futile;
5. That, I am executing this affidavit in order to attest to the truth of the
foregoing circumstances and for the purpose of reporting the loss of
the said Smart Mobile Number 09299607547 for replacement thereof
and for other legal purposes.
IN WITNESS WHEREOF, I have hereunto set my signature this
____________________, in Malaybalay City, Bukidnon, Philippines.

TEONILO P. TUBELLEJA
Affiant

SUBSCRIBED AND SWORN to before me this ____________________,

affiant exhibiting to me his valid identification card as sufficient proof of his
identity, known to me as the same person who executed the foregoing
instrument. I hereby certify that I have examined the affiant and I am
satisfied that he understood the contents of his affidavit and has voluntarily
executed the same in his own free will.

Doc. No. ________

Page No. ________

Book No. ________

Series of 2015