REPUBLIC OF THE PHILIPPINES)

CITY OF BAGUIO
) S.S

AFFIDAVIT OF LOSS
RE: __________
I, _________, of legal age, widower, Filipino citizen and a resident of
____________ after having been sworn in accordance with law hereby depose
and state that ;
1.

I am already a Senior Citizen and as such, I was issued a Senior Citizen ID

by the Office of the Municipal Social Welfare and Development of
_________;

2.

Further, I am a member of the __________________ and I was also issued

an ID by the Cooperative;

3.

However, last week, my jacket where I placed my Identification Cards was

stolen inside our house by unknown persons;

4.

I exerted all efforts to locate and recover said jacket with my Senior Citizen
and ________________ Identification Cards but my efforts proved futile as
I can no longer recover the same such that I now consider them as lost;

5.

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

and request Office of the ___________________ to replaced my IDS in
lieu of the lost ones and for all legal intents and purposes;

In witness whereof, I have hereunto set my hand this 26 th day of November

2013 at Baguio City, Philippines.
__________________
Affiant
CTC NO. 33123750/ 5-3-13
_______________

SUBSCRIBED AND SWORN TO before me this 26th day of November 2013 at

Baguio City Philippines.

Doc.No; 224
Page No. 47
Book No. XXIII
Series of 2013

_________________________
NOTARY PUBLIC
Until December 31,2013
PTR No. __________/IBP No._____
1-02-13/_______________