Republic of the Philippines )

Province of Pangasinan ) S.S.

Municipality of Umingan )
x……………………………. x

AFFIDAVIT OF LOSS OF SENIOR CITIZEN I.D.

I, ______________________, of legal age, widow, Filipino citizen, and a resident of

Brgy. ___________________________, after being sworn to in accordance with law, depose and
state:

That as a registered senior citizen of Brgy. ______________________________, I was

issued Senior Citizen Identification Card (ID) Number_________________;

That to my surprise, I discovered several days ago that the said Identification Card could
not be found;

As all efforts to find the same proved unrewarding, it is now safe to conclude that the
recovery of the same is no longer possible;

Thus, I execute this affidavit to establish its loss and to support my application for the
issuance of a new Senior Citizen Identification Card.

IN WITNESS WHEREOF , I have hereunto affixed my signature this ______ day of

__________ at Brgy. ____________________________, Philippines.

______________________
Affiant