Republic of the Philippines )

Camiling, Tarlac ) s.s.

AFFIDAVIT OF LOSS
I, AURORA B. BAUTISTA, 67 years old, Filipino citizen, married and a
resident of Barangay Surgui 3rd, Camiling, Tarlac, Philippines, after having been
duly sworn to in accordance with law, do hereby depose and state THAT:

1. On July 13, 2017, I placed my cardholder in my bag and rode a

passenger bus from Manila going to Camiling, Tarlac. My cardholder
contained my AFP Military Dependent ID card and Social Security System
(SSS) ID card;

2. After arriving in our house in Camiling, Tarlac, I checked the contents of

my bag and I discovered that my cardholder is missing. I searched for the
cardholder in other pockets of my bag could not find the same. I then
went to the bus terminal in Camiling Town Proper, Camiling, Tarlac to
look for the bus I boarded from Manila but it was not there anymore;

3. All efforts exerted to locate the said cardholder and its contents proved
futile; hence, I now consider them as lost and beyond recovery;

4. The above-stated ID cards were never pledged or used as a security to

any obligation;

5. I am executing this affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 8th day of

August, 2017 at Camiling, Tarlac, Philippines.

AURORA B. BAUTISTA
Affiant

SUBSCRIBED AND SWORN to before me on the date and place above.

Affiant exhibited before me her Senior Citizen ID Card with Control No. 04251
issued by the OSCA, Camiling, Tarlac.

Doc. No.:_______;
Page No.:_______;
Book No.:_______;
Series of 2017.