Republic of the Philippines )

City of Dumaguete ) S.S.

x - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, MARIO ESTORES, of legal age, Filipino, and a resident of San Miguel

Bacong, Negros Oriental, after having been sworn in accordance with law,
hereby deposes and states the following that:

1. I a registered senior citizen in the barangay of San Miguel, Municipality

of Bacong, Negros Oriental;

2. I was issued my respective OSCA ID with Control No. 3617 last

06/22/16;

3. I have placed the said ID in one of the pockets of my pants. However,

just last week, when I was looking for the said ID, I discovered it was no
longer in any of my shorts;

4. Despite diligent search and efforts to locate my wallet with my ID, I could
no longer find the same;

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

facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day

of _________ in Dumaguete City, Philippines.

MARIO ESTORES
 ID No. _____________
Affiant

SUBCRIBED AND SWORN TO before me this _____________

in Dumaguete City, Philippines, affiant exhibiting to me his competent proof of
identification.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.