REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF COTABATO )S.c.

X------------------------------------------X

AFFIDAVIT OF COMPLAINT

I, EFIPANIA V. GESULGA, of legal age, Filipino and a resident of N.D. Avenue,

Cotabato City, Philippines, after having been duly sworn to law, depose and state:

That I am the holder/registered owner of a SENIOR’S CITIZEN Identification

Card;

That sometimes in September 3, 2015, I discovered said SENIOR’S CITIZEN

Identification Card was missing believed to have been misplaced and nowhere to be
found;

That I have exerted my effort to locate said SENIOR’S CITIZEN Identification

Card but to no avail, hence considered lost;

That I am executing this AFFIDAVIT OF LOSS to attest to the truthfulness of the

foregoing facts and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day of June,

2016, at Cotabato City, Philippines.

EFIPANIA V. GESULGA
Affiant

SIGNED IN THE PRESENCE OF:

1. TITA MACUSE 2. BELINDA G. DE JOSE

SUBSCRIBED AND SWORN to before me this 2 nd day of June, 2016, at

Cotabato City, Philippines.

Doc. No. 1675

Page No. 335
Book No. XIII
Series of 2016