REPUBLIC OF THE PHILIPPINES )

__________________, METRO MANILA ) S.S.

AFFIDAVIT OF LOSS

I, LUISA BONAOBRA RAMOS, of legal age, widow, Filipino, with

residence address at No. 4, Petronia Road, Buenamar Subdivision, Quezon City,
Metro Manila, after having been duly sworn in accordance with law hereby
depose and state that:

1. I am the owner of Senior Citizen Identification Card

that was issued to me by Quezon City Government.

2. Sometime during the first week October 2017, I found

out that my Senior Citizen Identification Card was no longer inside
my wallet.

3. Despite all diligent efforts I have exerted to locate the

aforementioned the said Senior Citizen Identification Card, the same
can no longer be located. Hence, I have considered the said
identification card lost for all intents and purposes.

4. I am executing this Affidavit to attest to the truth of the

foregoing and for whatever legal purposes this Affidavit may serve.

LUISA BONAOBRA RAMOS

Affiant

SUBSCRIBED AND SWORN to before me this __________________ in

______________, Metro Manila by the affiant, exhibiting to me
_____________________________, a competent evidence of her identity under
Section 12 of the Rules on Notarial Practice.

Doc No. ______;

Page No. ______;
Book No. ______;
Series of 2017.