Republic of the Philippines )

Oton, Iloilo ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ______________, of legal age, Filipino, married, and a resident of

__________________ after having been sworn in accordance with law,
hereby deposes and states the following:

1. I am the owner and possessor of Social Amelioration Card (SAC)

under my name.
2. I have recently discovered that the said card is irretrievably lost and
can no longer be found despite diligent efforts to locate the same;
3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the ________________________________.

__________________
__________________________________

SUBSCRIBED and SWORN TO before me on the _____________ at

_______________. The affiant exhibited to me his competent evidence of
identity as indicated above.

Signed this _______________ at _______________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No.__ ;
Page No.__;
Book No. __;
Series of 2020