REPUBLIC OF THE PHILIPPINES )

Province of Isabela ) S.S.

Municipality of ______________ )
x-----------------------x

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, and a resident of ______________, Isabela,

after being duly sworn to in accordance with law, hereby depose and state:

That I am the same person executing this affidavit;

That I am a member of the Senior Citizens Association of ___________, Isabela and was
issued a senior citizen’s identification card;

That I kept my Senior Citizen identification card in my wallet;

That sometime in the month of December 2017, I went to _______, Isabela bringing with
me my wallet where I placed my senior citizen’s ID card;

That when I arrived at a friend’s house in __________, Isabela, I noticed that my wallet
was already missing;

That despite diligent search and efforts to locate my wallet and my senior citizen’s
identification card, the same could no longer be found such that I now believe it is
already lost beyond recovery;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
for any other purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

____________, Isabela

________________
Affiant

SUBSCRIBED AND SWORN to before me, this ________________ at _____________,

Isabela.

WITNESS MY HAND AND SEAL.