REPUBLIC OF THE PHILIPPINES)

Quezon City ) SS.

AFFIDAVIT OF LOSS

I, __, of legal age, married, and a resident of _________, after being sworn in accordance with
the law, hereby deposes and states the following:

1. I am the holder of a Senior Citizen Card issued by the Quezon City Office of Senior Citizen
Affairs;

2. The foregoing Senior Citizen Card with __________ was lost on _______ and can no longer
be found despite diligent efforts to locate the same;

3. That this affidavit was executed to attest the truth of the foregoing and for purposes of the
reissuance of a new Senior Citizen Card in my favor, and whatever legal purposes it may serve
best.

IN WITNESS WHEREOF, I hereunto affix my signature this ____day of November 2018 at

Quezon City.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Quezon City, Affiant

exhibiting to me his ________ bearing No. ______________________________ issued at
______________ on _________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of ________.