REPUBLIC OF THE 

PHILIPPINES )
Municipality of Sergio Osmeňa Sr., ) SS.

AFFIDAVIT OF LOSS

I, ELYN M. ASISTER, Filipino, of legal age, married, and a resident of San Juan,
Sergio Osmeňa Sr.,, Zamboanga del Norte under oath hereby depose and state:

1. THAT I am a registered owner/holder of a ATM card, being a

grantee/beneficiary of Pantawid Pamilyang Pilipino Program (4 PS) of the
Department of Social Welfare and Development (DSWD);
2. THAT sometimes on October, 2020 somewhere in our house in San Juan,
Sergio Osmeňa, Zamboanga del Norte , I discovered that I lost my ATM card
and other Identification Cards;
3. THAT I exerted diligent efforts to locate the said ATM card but to no avail and
I therefore considered the same as lost and can no longer be found;
4.  THAT I am executing this Affidavit to attest to the truth of the foregoing facts,
for the re-issuance of a new ATM card and for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 19 th day of

December, 2020 at Sergio Osmeňa, Zamboanga del Norte, Philippines.

ELYN M. ASISTER
Affiant
4PS Id No. 097214032-0130-00030

SUBSCRIBED AND SWORN to before me this 19 th day of December, 2020 at

Sergio Osmeňa, Zamboanga del Norte, affiant exhibited to me her valid proof of Identity
as above-stated.

ATTY. EARL RUSSELL S. PAULICAN

Notary Public
Until December 31, 2021
Roll No. 75530
PTR No. 2099861, 8/17/20, Dipolog City
TIN # 472-022-138
Notarial Commission No. SN: ZDN-DPL-042-2020

Doc No. ________;

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