Republic of the Philippines}

City of Panabo} S.S.

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

AFFIDAVIT OF LOSS
I, QUINTIN B. ACDAL, of legal age, Filipino, married and a resident of Purok 2,
Brgy. Katipunan, Panabo City, Davao del Norte, Philippines, after having been sworn
to in accordance with law, do hereby depose and state THAT:
1.

I was born on October 31, 1922 at Jagna, Bohol, Philippines;

2.

I was issued a Senior Citizen Identification Card from the City Social Welfare
and Development Office-Panabo City when I reached the age of Sixty (60)
years old;

3.
I usually place the above-mentioned Senior Citizen Identification Card inside
my wallet for
safe-keeping;
4.

Sometime in the second week of March, 2016, the Senior Citizen I.D was no
longer inside my wallet where I usually place it;

5.

I immediately exerted efforts to look for it but my efforts proved futile since it
was nowhere
to be found, and may now be considered as
LOST/MISPLACED;

6.

I am executing this Affidavit to attest to the truth of the foregoing facts as

requirement/s and for whatever legal purpose it may serve the premises.

IN WITNESS WHEREOF, I have hereunto set my hand this 21 st day of March

2016, at Panabo City, Davao del Norte, Philippines.

QUINTIN B. ACDAL
Affiant
CTC 00609513
Issued On March 21, 2016
Issued At Panabo City
SUBSCRIBED AND SWORN to before me this 21 st day of March 2016 at
Panabo City, Davao del Norte, Philippines.

Doc. No. ____;

Page No. ____;

Book No. ____;

Series of 2016.