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REPUBLIC OF THE PHILIPPINES )

Province/City Tabuk, Kalinga ) SS.

AFFIDAVIT OF LOSS

I, _____________________, of legal age, widow, Filipinos and residing/with


address at Purok 1, Bulanao Centro, Tabuk City, Kalinga, under oath, state
that:

1. A Senior Citizen’s ID card bearing a number of 15-112 was issued


to me by the Municipality of Tanudan on 8/7/2015;

2. I usually put said Senior Citizen’s ID card inside my wallet because


I used it for the benefits offered by being senior;

3. Sometimes on the month of December 2018, I look for it because it


is necessary for my identification to claim the monthly death
benefits of my late husband but I can no longer find it;

4. I exerted diligent efforts to locate said Senior Citizen’s ID card but


to no avail and I therefore considered the same as lost and can no
longer be found;

5. THAT I am executing this Affidavit to attest to the truth of the


foregoing facts and to use the same for whatever legal purpose it
may serve.

IN WITNESS WHEREOF, I hereby set my hands and signature this March 12,
2019 at Tabuk City, Philippines.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this March 12, 2019 at Tabuk City,
Kalinga, Philippines, affiant is known to me and known to me to be the same person
who executed the foregoing document.

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