Republic of the Philippines)

Taguig City )s.s

AFFIDAVIT OF LOSS

I, DOLORES D. DEL ROSARIO, of legal age, Filipino Citizen and a resident of No. 23 Los
Angeles St., Phase 4-C, Brgy. Bahay Pare, Meycauayan, Bulacan, after having been duly sworn to
in accordance with law, do hereby depose and state:

(1) That sometime in July 31, 2015, on my way to Quiapo Church, I lost my wallet;

(2) That the said wallet contains the following Identification Cards;

 GSIS e-Card
 Voters ID
 Seniors Citizen ID

(3) That efforts were made to locate the said wallet but proved futile;

(4) I am executing this affidavit to attest to the truth of the foregoing facts and consider the
above-mentioned Identification Cards lost and a new one be issued in lieu thereof.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th day of August 2015
at Meycauayan, Bulacan, Philippines.

DOLORES D. DEL ROSARIO

Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of August 2015, affiant exhibiting
to me her ________________________ with No. ___________________ as a competent proof
of her identity.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2015.