Republic of the Philippines)

City of Butuan )S.S.

AFFIDAVIT OF LOSS

I, PERLITA L. MOTOL, of legal age, Filipino, widow and a

resident of 186 San Vicente St., Pangabugan, Butuan City Agusan del Norte,
after having been duly sworn according to law, depose and state:

1. That I am a Senior Citizens I.D. (OSCA I.D.) holder, issued by

the Office for the Senior Citizens Affairs (OSCA), City Hall, Butuan
City;

2. That I lost the said Senior Citizens I.D. sometime this month of
August 2017 and that I exerted all efforts to locate the same but
could not remember exactly where I placed it and considered it
lost for all legal purposes;

3. That the said Senior Citizens I.D. was not confiscated by any
officer of the law by reason of any violation of any law, ordinance
or presidential decree, rules or regulation of the said Office;

4. That I am executing this Affidavit to inform the Office for the

Senior Citizens Affairs (OSCA), Butuan City that the said Senior
Citizens I.D. was lost and never recovered; and

5. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this August 29,

2017 in Butuan City, Philippines.

PERLITA L. MOTOL
Affiant

SUBSCRIBED and SWORN TO before me this August 29, 2017 in

Butuan City, affiant exhibiting to me her DepED I.D. with employee No.
5026518 and picture as proof of her identity.

Doc. No.: 64 ATTY. PEARL JOY M. SALAS

Page No.: 13 NOTARY PUBLIC
Book No.: V Commission until December 31 2017
Series of 2017 Roll No. 65035
IBP NO. 1061793 / 01-10-2017
PTR NO. 1260135 I 01-04-2017 /Butuan City
MCLE Compliance: Admitted to the Bar on 06-17-2016
TIN: 488-196-768
Purok-3 Libertad, Butuan City