REPUBLIC OF THE PHILIPPINES

CITY OF URDANETA } S.S.

AFFIDAVIT OF LOSS
I, RUDY V. LAFEGUERA, of legal age, Filipino, married, and a resident of Brgy.
Nancamaliran East, Urdaneta, Pangasinan, after having sworn to in accordance with law,
hereby, depose and state that:

1. I am the holder of a Social Amelioration Program (“SAP”) Form issued by the

Department of Social Welfare and Development (“DSWD”) for the purpose of claiming
assistance for citizens who are affected by the COVID-19 epidemic;

2. I safely kept my SAP Form in my wallet;

3. On 28 August 2020, I was about to claim my SAP benefit, but when I looked into my
wallet, I could not find my SAP Form;

4. I exerted diligent efforts to remedy the same, but to no avail, hence, it is considered
lost and beyond recovery;

5. As a requirement for the issuance of another SAP Form in lieu of the lost one, I am
required to execute an affidavit of loss;

6. In compliance with the abovementioned requirement, I hereby execute this affidavit

to request the authorities concerned to issue me a new SAP Form in lieu of the lost one, as well
as to allow me to temporarily claim ng SAP Benefit; and

7. I am executing this affidavit to attest to veracity of the foregoing facts and for
whatever legal purpose it may serve

IN WITNESS WHEREOF, I hereunto affix my signature this 28 th day of August 2020 in

the City of Urdaneta.

________________________
RUDY V. LAFEGUERA
Affiant

SIGNED IN THE PRESENCE OF:

___________________________ ___________________________
Witness Witness

SUBSCRIBED AND SWORN to before me on the date and place first above written,
affiant presenting to me, as competent proof of identity a photocopy of his Senior ID No. 3867
issued in Urdaneta City, Pangasinan.

Doc No.: 5
Page No.: 2
Book No.: II
Series of 2020.