REPUBLIC OF THE P HILIPPINES)

Province of Palawan) S.S.

City of Puerto Princesa)
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AFFIDAVIT OF LOSS

I, CHITA ABALLA SANDAHAN, Filipino, of legal age, married and a resident of

Barangay Tanglaw, Puerto Princesa City, after being duly sworn in accordance with law,
depose and state:

1. That I am bona fide holder of a Senior Citizen Identification Card (OSCA ID)
issued by the Office of the Senior Citizens Puerto Princesa City with control number
17366;

2. That in 2nd week of July 2019, when I was on my way home, I inadvertently lost
my wallet where the said OSCA ID was placed;

3. That despite diligent search and efforts to locate the wallet where the
aforementioned OSCA ID was placed, I could not find the same such that I now believe
that it is now lost beyond recovery;

4. That the aforementioned OSCA ID was valid at the time of its loss;

5. As such, I am executing this Affidavit of Loss for the reissuance of a new

OSCA ID in lieu of what was lost and to attest to the truth of the foregoing and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________________

in the City of Puerto Princesa, Palawan.

CHITA ABALLA SANDAHAN

TIN: 130-225-556
Affiant

SUBSCRIBED AND SWORN to before me, this this ___________________ in the City
of Puerto Princesa, by the Affiant whom I have identified through competent proof of
identity indicated under her name.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2019