Republic of the Philippines )

Province of Cavite ) S.S.

Trece Martires City )

AFFIDAVIT OF LOSS

I, CHERUBINE G. PECSON, of legal age, Filipino citizen, single, and a resident of 085
Bailen St., Purok 2, Brgy. Osorio, Trece Martires City, Cavite, Philippines, after being sworn in
accordance with law hereby depose and say;

1. That I am the a Person With Disability (PWD for brevity);

2. That as PWD I was issued of an Identification Card which was the details I could no
longer recall;

3. That on this day 21st day of November around 9:00 o’clock in the morning the above
said PWD identification was lost or missing for the reason of it was fell from my
possession;

4. That fervent efforts to retrieved the missing PWD Identification Card proved
ineffective as it is now declared loss for all legal purposes;

5. That the above said PWD Identification was not use as a collateral in any
government or private lending institutions;

6. That I am executing this affidavit to attest the truthfulness of the foregoing

declarations under penalties of perjury to respectfully request the concerned office
for the RE-ISSUANCE of a new PWD Identification Card, moreover to further serve
all legal intents and purpose.

IN WITNESS WHEREOF, I have hereto affixed my signature on this 21 st day of November

2023 at Trece Martires City, Cavite.

CHERUBINE G. PECSON
Affiant

SUBSCRIBED AND SWORN to before me in the Trece Martires City, Cavite, Philippines,
this 21st day of November 2023, that she is the same person who is personally signed before me
the foregoing Affidavit of Loss and acknowledged that she executed the same.

Doc. No. : ______

Page No. : ______
Book No. : ______
Series of : 2023