REPUBLIC OF THE PHILIPPINES)

) S.S.
CALOOCAN CITY )

AFFIDAVIT OF LOSS

I, MELECIO FORTO, 75 years old, and residing at #1038 Int. 2 A. Mabini St.
Maypajo, Caloocan City, after having been sworn according to law, hereby depose
and state that:

1. I am the owner of the Senior Citizen Purchased booklet with SC No. S-

5042 issued by the Office of the Senior Citizen Affairs (OSCA).
2. On or about 11:00 in the morning, 27th day of November 2022, my son
NOEL FORTO discovered the loss of the said Senior Citizen Purchased
Booklet under the following circumstances:
- My son went to the grocery store to purchased my needs and when he
was able to go back home he found out that it is lost.
3. Despite diligent efforts, We could not find nor locate the same and I believe
that it is truly lost.
4. I am executing this affidavit for whatever legal purpose it may serve and to
request for a replacement of the said Senior Citizen Purchase Booklet.

MELECIO FORTO
Affiant

SUBSCRIBED AND SWORN to before me this _________________ at

______________________.