REPUBLIC OF THE PHILIPPINES

)
PROVINCE OF NEGROS OCCIDENTAL ) S.s.
CITY OF SAGAY
)
X -----------------------------X
AFFIDAVIT OF LOSS
I, SOL PORTUNES MENDIETA, of legal age, Filipino, widower, and a resident of
Prk. Crotons A, Brgy. Old Sagay, Sagay City, Negros Occidental, after having been duly
sworn to in accordance with law, hereby state that:
I am a bona-fide holder of an ATM Card issued by Land Bank of the
Philippines- Sagay City;
Sometime in October 1, 2015, I asked my child, VAN MENDIETA, to check
my ATM at LandBank;
He put the said ATM Card inside his wallet along with other important IDs
and other important documents therein;
While he was on his way to the bank, he put the same wallet in his back
pocket while he ride the tricycle, and upon arrival at the bank, and while reaching
for his wallet, he was surprised that the same was nowhere to be found;
Despite diligent efforts exerted to seek the recovery of the said missing item,
the same remains lost up to this time and proved to be beyond recovery already;
This affidavit is executed to attest to the truth of the foregoing

statements,

as well as to inform the authorities concerned and for whatever legal purpose it
may properly served.
IN

WITNESS

WHEREOF,

have

hereunto

set

my

hand

this

__________________________ at Sagay City, Philippines.

SOL PORTUNES MENDIETA

Affiant
SUBSCRIBED AND SWORN to before me at Sagay City, Philippines, this
________________________ affiant exhibited to me her valid identification with ID
No.0001357 duly issued by OSCA- Sagay City.
Doc. No.: ________
Page No.:________
Book No.: ________
Series of 2015.