REPUBLIC OF THE PHILIPPINES)

: S.S.
VICTORIAS CITY )
X-----------------------x

AFFIDAVIT OF LOSS

I, RHODA A. CASAMAYOR, of legal age, Filipino, with

residence at Victorias City, Negros Occidental, after first being duly sworn
according to law, depose and say:

1. That I am a member of Office for the Senior Citizens Affairs

(OSCA);

2. That as a member, I was issued an OSCA identification card;

3. That the said OSCA identification card was lost and despite
repeated efforts to locate the same, said OSCA identification
card could no longer be found or located and they are already
lost and gone;

4. That I am executing this affidavit in order to state the fact of

the loss of the said OSCA identification card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___ day of __________________2020 at Victorias City.

RHODA A. CASAMAYOR
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of

___________ 2020 at Victorias City.