Republic of the Philippines)

Province of ____________ ) S.c.

Municipality of ___ )

AFFIDAVIT OF LOSS
(CASH CARD)
I, _____________, Filipino, 41 years old, married and a
resident of Brgy. Pob. I, Banisilan, Cotabato, after having been
duly sworn to in accordance with law do hereby depose and state:

1. That I am a member of the Pantawid Pamilyang Pilipino

Program with HH ID No _________________. As such, I was
issued a CASH CARD;

2. That on January 2019, when I was about to withdraw at the

ATM of LBP- _____________, I discovered that my CASH CARD
was missing;

3. That despite diligent search and efforts I could not find

the same such that I now believe that it is now lost beyond
recovery;

4. As such, I am executing this Affidavit of Loss to attest

to the truth of the foregoing and for whatever legal purpose
it may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 27th day of August 2020 at ________________, Philippines.

_____________
Affiant

SUBSCRIBED AND SWORN to before me this 27th day of August

2020 at ____________, Philippines. Affiant having exhibited to me
her 4Ps DSWD ID with No. ________________ as competent proof of
identity.