REPUBLIC OF THE PHILIPPINES  )

CITY     OF   SURIGAO   ) S. S.
X----------------------------------------------X
 
AFFIDAVIT OF LOSS 

I, JELLY B. MALBACIAS, Filipino, of legal age, widow and a resident of P-3,

Brgy. San Juan, Surigao City, Philippines, after having duly sworn to in accordance
with law, hereby depose and say that:

1. I am a holder of a PANTAWID PAMILYANG PILIPINO PROGRAM

Identification Card (4Ps I.D.) issued by DSWD, Surigao City, on March 9,
2011;

2. The said 4Ps I.D. was in my possession until I found out that it was
missing last February 2016;

3. I exerted diligent search and efforts to locate the said I.D. but the same
remains futile;

4. Hence, it is now safe to declare that said 4Ps ID is lost and beyond
recovery;

5. As such, I am executing this affidavit to attest to the foregoing facts, to

establish its loss and for whatever legal purpose that this affidavit may
serve;
 
       IN WITNESS WHEREOF, I have hereunto set my hand this March 30, 2017, in
the City of Surigao, Philippines.
                                
         JELLY B. MALBACIAS
Affiant

SUBSCRIBED AND SWORN to before me this March 30, 2017, at Surigao

City, Philippines.