Republic of the Philippines }

Quezon City, Metro Manila} S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ________________________ of legal age, Filipino, single/married, and a

resident of ____________________________________________________, after having
been sworn in accordance with law, hereby deposes and states the following:

1. That I am a Senior Citizen I.D. holder, issued by the Office for the Senior
Citizens Affairs (OSCA), City Hall, Quezon City;

2. That I have recently discovered that the said item is lost sometime in
______________ and can no longer be found despite of diligent efforts to
locate the said item and considered it lost for all legal purposes;

3. That the said identification card was not confiscated by any officer of the law
by reason of any violation of any law, ordinance or presidential decree, rules
or regulation of any office; and

4. That I execute this affidavit to attest to the truth of the foregoing.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this _______, 20____ in

Quezon City, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______, 20____ in Quezon City,

affiant exhibiting to me her SSS I.D. with a no. ______________ and picture as proof of
her identity.

Notary Public
Doc. No.
Page No.
Book No.
Series of ______