REPUBLIC OF THE PHILIPPINES )

CITY OF IMUS, CAVITE ) S.S.

AFFIDAVIT OF LOSS

I, ADELA BAYTING LANTAPON, Filipino, of legal age, and presently

residing at Athena Riverside Anabu II-D, City of Imus, Cavite, after having been
sworn according to law, hereby depose and state that:

1. I am previously a holder of a Senior Citizen Identification Card (ID),

bearing the name of Adela Bayting Lantapon;

2. While I was having a meal in Jollibee, I inadvertently lost my Senior

Citizen ID. Only after going back home, I realized I lost the said ID;

3. I immediately went back to the said establishment to look for it. Despite,
exerting diligent efforts on my part to locate or search for lost Senior
Citizen ID, the same could no longer be found

4. As such, I am executing this Affidavit of Loss to attest to the truth and

veracity of the foregoing facts and to establish such loss for the purpose
of securing a new copy thereof from the Office of the Senior Citizen
Affairs.

ADELA BAYTING LANTAPON

Affiant

SUBSCRIBED AND SWORN TO before me this ___________ at

________________, affiant exhibiting to me her valid proof of identification.

Doc. No. _____;

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