Republic of the Philippines….

)
Buenavista, Agusan del Norte) S.S.
x---------------------------------------x

AFFIDAVIT OF LOSS

I, ARSENIA P. TAMPOS, of legal age, Filipino, single, and a resident of

Barangay 9, Buenavista, Agusan del Norte, Philippines, after having been sworn to in
accordance with law, do hereby depose and state THAT:

1. I am a holder of Pantawid Pamilyang Pilipino Program (4Ps) ID No.

160201021-0121-00004 from Barangay 9, Buenavista, Agusan del Norte;

2. That last Month, June 04, 2023, when I tried to retrieve the above-
mentioned Pantawid Pamilyang Pilipino Program (4Ps) ID from my filing cabinet
where I keep all my important documents, I could no longer locate the same;

3. That I continued to search the subject Pantawid Pamilyang Pilipino

Program (4Ps) ID at all possible places that I could have kept it, but, much to my
dismay, and despite my diligent search, I could no longer locate it;

4. That without said Pantawid Pamilyang Pilipino Program (4Ps) ID

evidencing my transaction with them, I could neither renew nor redeem my above-
described Pantawid Pamilyang Pilipino Program (4Ps) ID;

5. That I executed herein affidavit to: (a) attest to the truth of the foregoing
facts above-stated; (b) to comply with the documentary requirement serving as
basis for the issuance of a new Pantawid Pamilyang Pilipino Program (4Ps) ID
covering the same transaction; (c) to serve as my temporary Pantawid Pamilyang
Pilipino Program (4Ps) ID in lieu of the lost one in order to either renew or redeem
my pledged items and for no other purpose contrary to law.

IN WITNESS WHEREOF, I hereunto affixed my signature this 4 th day of July

2023 at Buenavista, Agusan del Norte, Philippines.

ARSENIA P. TAMPOS
Affiant
Senior Citizen ID No._____________

SUBSCRIBED AND SWORN TO BEFORE ME, this 26th day of June 2023 at
Buenavista, Agusan del Norte, Philippines. I hereby certify that I personally examined
the affiant and I am convinced that he personally executed this Affidavit freely and
voluntarily and he understood the same.

Doc. No. _____

Page No. _____
Book No. _____ GENE ESTEBAN S. PRISCO, JR.
Series of 2023. Notary Public until Dec 31, 2024; Roll No. 72316
IBP No. 205846 (2023); PTR No. 8661455 (2023)