REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NORTHERN SAMAR ) S.S.

MUNICIPLAITY OF CATARMAN )

AFFIDAVIT OF LOSS

I, LOURDES A. OLMEDO, of legal age, a Filipino Citizen and a resident of Brgy.

Kasoy, Catarman, Northern Samar, after having been duly sworn to in accordance
with law do hereby depose and state:

1. That I am the holder of a Senior Citizens Identification Card issued by the

Office of the Senior Citizens Affairs (OSCA);

2. That sometime on November 2019 I have misplaced such Identification

Card and have been looking for it ever since;

3. That through my efforts I have not found said Identification Card and
hereby declare it to be lost and beyond recovery;

4. That I am executing this affidavit of loss for the purpose of applying for a
new Senior Citizens Identification Card in lieu of the misplaced one and for
whatever legal intents and purposes this document may serve with the
Office of the Senior Citizens Affairs.

Affiant further sayeth naught.

IN WITNESS THEREOF, I have hereunto set my hand this ________ day of

_______________ 2020, at Catarman, Northern Samar, Philippines.

LOURDES A. OLMEDO
Affiant
_________________________________

SUBSCRIBED AND SWORN to before me this ______ day _______________ 2020, at

Catarman, Northern Samar, affiant exhibiting to me competent proof of her identity
through her identification card as indicated above.

Doc. No._____
Page No._____
Book No._____
Series of 2020