Republic of the Philippines )

_____________________ ) Sc.
x-----------------------x

AFFIDAVIT OF LOSS

I, ______________________, of legal age, Filipino, married and a resident of

__________________________, Philippines, after being duly sworn in accordance with
law, depose and state:

That I am a Senior Citizen and for which a Senior Citizen ID Card with Number
______________ was issued by Office of the Senior Citizen Affairs –City of Cabuyao;

That sometime on ______________________, I discovered the above-

mentioned ID Card was missing probably fell from pocket and the same was not
recovered;

That despite diligent search and efforts to locate the said ID Card, I could not find
the same such that I now believe that it is now lost beyond recovery;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support the application for the issuance of new one in lieu of the one which was
lost and for whatever legal purpose that may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________ at City of Cabuyao, Laguna, Philippines.

________________________
_
Affiant

SUBSCRIBED AND SWORN to before me, on the above mentioned date by the
Affiant whom I have identified through competent evidence of identity and who exhibited
her photocopy of her ____________________________.

Doc No. ________;

Page No. _______;
Book No. _______;
Series of 2025.