Republic of the Philippines)

Province of Negros Oriental) S.S.

Municipality of Sibulan . . .)
x- - - - - - - - - - - - - - - - - - - - -/
AFFIDAVIT OF LOSS
I, MARIA PAZ A. VILLACORTE, of legal age, Filipino, married, and a resident of
Barangay Poblacion, Sibulan, Negros Oriental, after having been sworn to in accordance with the
law, do hereby depose and say the following, to wit:
That I am a holder of a Senior Citizens Identification Card issued by the Office of the
Seniors Citizens Affairs of Sibulan, Negros Oriental which I placed inside my wallet together
with my other identification cards and cash;
That sometime on August 3, 2016, I went on a trip to Palo, Leyte and I remember taking
out of my wallet the said Senior Citizens Identification Card to avail of the Senior Citizens
discount offered by the ferry we took from Leyte to Cebu;
That when we arrived at our residence in Sibulan, Negros Oriental, I can no longer locate
my Senior Citizens Identification Card;
That I tried to communicate with the office of the ferry but they failed to find my Senior
Citizens Identification Card;
That efforts were exerted to locate the aforementioned identification card, but in spite of
diligent search, it could not be found and the same is now beyond recovery;
That it is for this reason that I now consider the abovementioned Seniors Citizen
Identification Card as lost and irretrievable for all legal intents and purposes;
That I am executing this affidavit, freely and voluntarily, in order to attest to the veracity
of the facts above-stated and in order to acquire a substitute Senior Citizens Identification Card
in lieu of the lost ones;
IN WITNESS WHEREOF, I hereby affix my signature this 17 th day of August, 2016 at
Sibulan, Negros Oriental, Philippines.

MARIA PAZ A. VILLACORTE

Affiant
SUBSCRIBED AND SWORN TO before me this _____________________ at
Dumaguete
City,
Negros
Oriental,
affiant
exhibited
to
me
her
_____________________________ as a proof of her identity.
Doc. No. ________;
Page No. ________;
Book No. ________;
Series of 2016.