Republic of the Philippines )

City of Butuan )S.S.

AFFIDAVIT OF LOSS

I, ANITA SANTOYA TABADA, of legal age, Filipino, married

and a resident of Village II, Libertad, Butuan City Agusan del Norte, after
having been duly sworn according to law, depose and state:

1. That I am a Senior Citizen’s 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 Citizen’s I.D. sometime last month of
October 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 Citizen’s 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
Citizen’s 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 ____ day

of November 2017 in Butuan City, Philippines.

ANITA SANTOYA TABADA

Affiant

SUBSCRIBED and SWORN TO before me this _____ day of

November 2017 in Butuan City, affiant exhibiting to me her
_________________________ as proof of her identity.

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