REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

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

AFFIDAVIT OF LOSS

I, MA. LOURDES M. SORIANO, of legal age, Filipino, single and a resident of 1479
SH Loyola St. Sampaloc, Manila, after having been duly sworn to in accordance with law,
depose and state:

1. That I am a holder of Automated Teller Machine (ATM) Card No. 1437102488 duly issued in
my favor by Landbank of the Philippines (Tayuman Branch)

2. That I used to put said ATM card in my wallet;

3. That sometime on September 29, 2016, when I arrived home from work, I discovered that
said ATM card was no longer in my wallet;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request Landbank of the Philippines to issue
another ATM card in lieu of the lost one;

6. That I bind myself to save Landbank of the Philippines 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 3rd day of October 2016 in
Metro Manila, Philippines.

MA. LOURDES M. SORIANO

Affiant

PRC ID No. 0713175

SUBCRIBED AND SWORN TO before me this 3rd day of October 2016 in Metro
Manila, Philippines, affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.