REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.

AFFIDAVIT OF LOSS

I, MARIA KURDABA of legal age, single, Filipino and with address at

______________________________, Philippines, after having been duly sworn to in
accordance with law hereby voluntarily depose and say:

1. I am the holder of Person With Disability (PWD) Identification (ID) card issued
by the Department of Social Welfare and Development (DSWD);

2. I have placed my PWD ID including some personal documents and other IDs in
my wallet, unfortunately I lost my wallet sometime on May of 2018;

3. I tried to find and search the places where I have been and I could have possibly
placed my wallet containing my PWD ID however despite diligent efforts
exerted, I could no longer locate, find or recover my wallet where my PWD ID
was placed and to the best of my knowledge, the same is truly lost;

4. The said PWD ID has not been confiscated by any officer of the law or issuing
office or agency due to the violation of any law, statute, order, rule or
regulation;

5. In the event that the lost PWD ID should thereafter be found or locted, I
undertaked to forward or surrender the same to DSWD for appropriate
disposal;

6. I am executing this Affidavit of Loss to attest to the truth of the foregoing facts
and to request for the issuance of a new PWD ID in lieu of the one which I lost.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________ day of

______________ at the City of Iloilo, Philippines.

MARIA KURDABA
Affiant

SUBSCRIBED AND SWORN to before me this ___________ day of

_____________, at the City of, Philippines. Affiant exhibited to me his
____________________, bearing his signature and photograph.

Doc. No.________;
Page No._______;
Book No. ______;
Series of 2018.