REPUBLIC OF THE PHILIPPINES)

City of Mandaue) S.c.

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AFFIDAVIT OF LOSS
I, NARCISA PURGATORIO GUIDO, Filipino, of legal age, married and a
resident of 5th Street Ext., Doña Rosario Village, Labogon, Mandaue City,
Philippines, after being duly sworn to in accordance with law, hereby depose and
state:

1 That I am already Sixty-EIGHT (68) years of age, which in effect a

bona fide member of the Senior Citizen Organization of Mandaue City
and consequently was issued a Senior Citizen Identification Card;

2 That sometime on the last week of March 2015, while I was inside Rose
Pharmacy in Tabok, Mandaue City, the same Senior Citizen Identification
Card was lost without my knowledge;

3 That despite diligent search and efforts to locate my Senior Citizen

Identification Card, I could not recover the same such that I now
believe that it is now lost beyond recovery;

4 That said Senior Citizen Identification Card has not been confiscated by
any government agency or by any private individual;

5 As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and for whatever legal purpose this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 15 April 2015

at Mandaue City, Philippines.

NARCISA PURGATORIO GUIDO

AFFIANT

SUBSCRIBED AND SWORN to before me, this 15 April 2015, by Affiant,

NARCISA PURGATORIO GUIDO, who exhibited her COMELEC VIN: 2230-0406A-
J2946NPG20000 and to me known to be the same person who personally signed the
foregoing Affidavit of Loss.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2015.