Republic of the Philippines )

Province of Benguet ) s.s.

AFFIDAVIT of LOSS
(Re: 4P’s Cash Card)

I, RANA C. SEYERES, of legal age, married, Filipino citizen and a resident of

Bangao, Buguias, Benguet, under oath hereby depose and state THAT:

I am a holder and possessor of a 4P’s cash card issued by the Department of

Social Welfare and Development (DSWD) which I carefully kept inside my black wallet
for safekeeping purposes;

Just recently however, I noticed that the cash card inside my wallet is missing. I
searched our house and our filing cabinet in the hope of finding the same but all of my
efforts turned out futile;

Its where about cannot be located despite deligent efforts undetaken and I am
now of the honest belief that said Cash Card is beyond recovery;

Said cash card was not confiscated, revoked or cancelled by the issuing any
government agency for violation of its rules and regulations nor deposited to another
person for monetary obligations or for illicit purposes; and

I am executing this affidavit to attest to the truth of the foregoing facts especially
in support of my request for the issuance of a replacement of said cash card and for all
legal intents and purposes it may serve.

In Witness Whereof, I have hereunto set my hand this 23 rd day of April 2015 at
Buguias, Benguet, Philippines

ANA C. SEYERES
Affiant

SUBSCRIBED AND SWORN to before me this 23 rd day of April 2015 at Buguias,

Benguet, Philippines, affiant exhibited to me her 4P’s ID No. 000001111122222 and
further acknowledged to me that the same is her free acts and deeds.

Doc. No. 305;

Page No. 61;
Book No. XXXIII;
Series of 2015