Republic of the Philippines)

City of Baguio ) S.S.

x--------------------------------------x

AFFIDAVIT OF LOSS

I, Ruben Ramirez Balangue, Filipino, of legal age and a resident of 248 Evangelista St Road
2 Leonila Hill Baguio City Philippines, after being duly sworn in accordance with law, depose and
state:

1. That I am the owner of Senior ID with number 25856, issued on June 5, 2014 at Marikina City;

2. That on March 20, 2023, I lost my wallet with my cards and Identification including my Senior
ID;

3. That despite diligent search and efforts to locate said cellular phone, I could not find the same
such that I now believe that said is now lost beyond recovery together with the aforesaid Senior ID Card;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and in support
of my request / application for the replacement of the said Identification Card.

IN WITNESS WHEREOF I have hereunto set my hand this ____ day of _____ 2023
at____________, Philippines.

_______________________________________
RUBEN RAMIREZ BALANGUE
Affiant
Tin No.: 221-721-727

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me her competent evidence of identity by
way of a Philippine Passport issued at______________ on___________________

Doc. No. ____

Page No. ____
Book No. ____
Series of 20__