REPUBLIC OF THE 

PHILIPPINES)
CITY OF LAS PIÑAS            ) S.S.
x----------------------------x
  

AFFIDAVIT OF LOSS

 I, ___________________________________, Filipino, of legal age, married and

a resident of _________________________________________________, Philippines,
after being duly sworn to in accordance with law, hereby depose and state:

1 That I am already _____________ years of age, which in effect a bona fide

member of the Senior Citizen Organization of Las Piñas City and
consequently was issued a Senior Citizen Identification Card;

2 That sometime on the _____________________, while I was __________

___________________________________________, the same Senior

Citizen Identification Card was lost without my knowledge;

3 That despite diligent search and efforts to locate my Senior Citizen

Identification Card, I could not recover the same such that I now believe that
it is now lost beyond recovery;

4 That said Senior Citizen Identification Card has not been confiscated by any
government agency or by any private individual;

5 As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and for whatever legal purpose this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ 2023 at

Las Piñas City, Philippines.

_______________________________
AFFIANT

 SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence
of identity by way of __________________ issued at ______________
on __________________.

Doc. No. _____;

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