Republic of the Philippines )

DONE: In the City of Baguio) S.S.

AFFIDAVIT OF LOSS

I, ________________, Filipino citizen, of legal age, married, and a resident of

Paraan St., Victoria Village, Bagui City, Philippines, after having been duly sworn
in accordance with law, do hereby depose and state that:

1. I am a bona fide holder/owner of Office of the Senior Citizens Affairs

(OSCA) Identification Card;

2. Sometime in March 2023 on my way to Pampanga, I gave my OSCA ID

Card to the conductor of the bus for fare discount, and I could not recall if
said ID Card was returned to me thereafter;

3. I just discovered upon returning home to Baguio City that said ID Card
was missing;

3. I went back to the bus station and try to look for my ID Card, but failed to
find among the lost and found ID Cards;

4. Despite my very best efforts and exercise of reasonable diligence to find

the said identification card, I could not find the same such that I have good
reason to believe the same is now lost and beyond recovery;

5. Said card has not in any way been confiscated nor apprehended for any
violation of any law, rule, or regulation; and

6. I am executing this affidavit in order to attest to the truthfulness and

veracity of the foregoing and to facilitate the replacement of the
identification card above-described.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th day of

May 2023 in Baguio City, Philippines.

__________________________
PHL ID No.: ___________________
Issued on: January 27, 2023
Issued at: Baguio City
Affiant

SUBSCRIBED AND SWORN to before me this 24th day of May 2023, the affiants
having shown to me their government issued identification cards bearing details
as stated below their names.

Doc. No.: ____

Page No.: ____
Book No.: ____
Series of 2023: