REPUBLIC OF THE PHILIPPINES)

BAUAN, BATANGAS ) S. S.

AFFIDAVIT OF LOSS

I, ANASTACIA MARIA EXCELSIS NIETES EBORA, married, of legal

age, Filipino Citizen, and a resident of Dinar St. Cristina Homes 2 Sambat, San
Pascual Batangas, on oath, depose and say:

That I am a holder of OSCA ID issued by Municipality of San

Pascual;

That I misplaced the said ID while ordering in Jolibee Bauan on

January 17, 2023, I found out that it was lost;

That I exerted diligent efforts to locate the same, but I failed to find it;

That it probably has been lost and the same are beyond recovery;

That I am executing this affidavit for the purpose of affirming the

foregoing facts and so that I may use this for all legal purposes and intent.

IN WITNESS WHEREOF, I signed this affidavit this _________________

at Bauan, Batangas.

ANASTACIA MARIA EXCELSIS NIETES EBORA

Affiant
PRC ID No. 1236112

SUBSCRIBED AND SWORN TO before me this ____________________

at Bauan, Batangas, affiant exhibiting to me her valid proof of identification as
described above.

Doc. No. ___ ;

Page No. ___ ;
Book No. ___ ;
Series of 2023.