REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ZAMBALES) S.S.

MUNICIPALITY OF IBA)
x-------------------------------------x

AFFIDAVIT OF LOSS

I, MARIA BERNADETTE BASA, of legal age, Filipino, single and a

resident of Purok 1, San Isidro, Botolan, Zambales 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 duly issued in my

favor by Land Bank of the Philippines, Inc.;

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

3. That sometime on October 02, 2018, my bag is snatch in Manila, I discovered

my ATM is belong at my bag;

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

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

6. That I bind myself to save Land Bank 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 ____ day

of _________________ at Iba, Zambales, Philippines.

MARIA BERNADETTE BASA

Affiant

SUBCRIBED AND SWORN TO before me this ____ day of ___________

at Iba, Zambales, Philippines, affiant exhibiting to me her ____________ ID
with number _________________ as valid proof of identification.

Doc. No. _____;

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