AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES]

PROVINCE OF ALBAY
] SS.
I, ANNABELLE ESPERON BORROMEO, of legal age, married and a resident of Camp General
Simeon A. Ola, Legazpi City after having been duly sworn on oath in accordance with law hereby
voluntarily depose and say:
1. That I am presently employed at Regional Training Center 5, Philippine Public Safety
College, Camp General Simeon A. Ola, Legazpi City.
2. That I am a holder of LandBank ATM with Savings Account Number 0557-1540-78
3. That last June 14, 2016 after I withdrew from an ATM Machine located in Metro Gaisano , I
accidentally lost my wallet while I was riding in Jeepney going home, That I notice the loss
only when, upon reaching my destination, I saw that my wallet was gone together with my
LANDBANK ATM CARD.
4. That I took pains and exerted effort to find said wallet but to no avail.
5. That I am executing this statement to attest to all the above facts, and to request Landbank for
issuance of new ATM Card.
IN TRUTH WHEREOF, I have hereunto signed my name below, this ____ day of June 2016 at
Legazpi City.

ANNABELLE E. BORROMEO
Affiant

SUBSCRIBED and SWORN to before this _____day of ____________________________ at Camp

General Simeon A. Ola, Legazpi City, Philippines. Affiant exhibited to me his CTC no.
______________________ issued at ______________________ on _________________________2016.

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