Republic of the Philippines )

City of Bacolod )Sc.

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

AFFIDAVIT OF LOSS

I, GLENN PAUL D. LADINES, of legal age, Filipino, single and a resident of PHHC,
Brgy. Montevista, Bacolod City, after having been duly sworn to in accordance with law, do
hereby depose and say:

1) That I am a a holder of an ATM Savings Account with the

Development Bank of the Philippines under Account Number 0710-615843-501;

2) That sometime this June 2017, my wallet was stolen and unfortunately,
my ATM card was in my wallet;

3) That diligent effort was exerted to search for my ATM Card but to no
avail and that for all intents and purposes, the said ATM card is now considered
lost and beyond recovery;

4) That the ATM card was not mortgaged at any financing company, or
was not surrendered to anybody in exchange of lending transactions;

5) That this Affidavit is now being executed to attest to the truth of all the
foregoing statements and to serve as basis for a new ATM Card to be issued in
lieu of the lost one;

6) That this Affidavit will serve as my unqualified undertaking and/or of

the corporation or entity represented by me if such is the case, to hold the Bank
free and harmless from any loss or liability of whatever nature that it may incur
or stand to incur by reason of or as a consequence of acceding to my request
including but not necessarily limited to the obligation to honor in the hands of a
holder in due course the ATM said to be lost, destroyed or stolen.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___ day of ___________, in Bacolod City, Philippines.

GLENN PAUL D. LADINES

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of _________ 2017,

in Bacolod City, Negros Occidental, Philippines.

Doc. No. _____;

Page No._____;
Book No._____;
Series of 2017.