Republic of the Philippines )

City of -- ) S.S.

AFFIDAVIT

I, --, 81 years old, married, and a resident of --,

Philippines, after having been duly sworn to an oath in
accordance with the law, hereby depose and say:

1. That I am the owner of a Senior Citizen ID issued by

Office for the Senior Citizen Affairs of --;
2. That I lost my Senior Citizen ID sometime last 2021 when
I went to Metro Manila;
3. That despite due diligence and earnest efforts to locate it,
the same proved futile;
4. That the said Senior Citizen’s ID was not confiscated by
any officer of the law by the reason of any violation of any
law, ordinance, or presidential decree, rules, or
regulations of the said office.
5. That I am executing this Affidavit to inform OSCA -- that
the said Senior Citizen’s ID was lost and never recovered;
and
6. That I attest to the truth of the foregoing facts.

FURTHER AFFIANT SAYETH NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this

13th day of June 2023, in --, Philippines.

--
Affiant

SUBSCRIBED AND SWORN TO before me this 13th day of

June 2023, --, Philippines, affiants exhibiting his valid
Government-issued ID for identification.