REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF BATANGAS ) S.S.

AFFIDAVIT OF LOSS

I, PERLITA A. TABISAURA, married, of legal age, Filipino, and a

resident of Brgy. Cuta, Batangas City, after having been duly sworn
according to law depose and say, That:

I was issued a Senior Citizen’s Identification Card by the Office of the

Senior Citizen’s Affairs, Batangas City with number 29462;

Sometime in June, while I was in the bus, I noticed that my Senior Citizen
Identification Card was not in my bag where I usually kept it as it might have
slipped-off unnoticed;

I exerted diligent efforts to find and locate said card but the same proved
futile;

I am executing this affidavit to attest to the truth of all the foregoing

facts and to inform the proper authorities of the loss of the above-stated
Senior Citizen’s Identification Card and for whatever legal purpose this may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this July 4, 2018

at Batangas City.

PERLITA A. TABISAURA
Affiant
TIN: 100-049-334-000

SUBSCRIBED AND SWORN to before me this July 4, 2018 at

Batangas City, affiant exhibiting to me his TIN stated above.