REPUBLIC OF THE PHILIPPINES)

CITY OF DIPOLOG )S.S

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AFFIDAVIT OF LOSS OF CASH CARD FOR PANTAWID

KNOW ALL MEN BY THESE PRESENTS:

I, JEANNYVIE P. ANDUS, Filipino, of legal age, single, and a resident of

Nangcaan, Rizal, Zamboanga del Norte, after having sworn to in accordance with
law, depose and say that:

That I was the holder/safekeeper of a CASH CARD for PANTAWID which is

under the name of my younger brother named as DANIE P. ANDUS, 13 years of
age, single, and a resident of Nangcaan, Rizal, Zamboanga del Norte;

That I noticed that said Cash Card was lost on my way while I was riding a
motorcyle from Rizal to our residence sometime in September, 2020;

That despite earnest efforts exerted, it could nowhere be found, thus I now
deem it as lost forever.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 6th day of

October, 2020, at Dipolog City, Philippines.

JEANNYVIE P. ANDUS
Affiant
_____________________________

SUBSCRIBED, SIGNED, AND SWORN TO in my personal presence, this 6th

of October, 2020, at Dipolog City, Philippines, affiant presenting her competent
proof of identity, the particulars of which are above-cited, and who avowed under
penalty of law to the whole truth of the contents of the instrument or document,
which she executed freely and voluntarily.

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