Republic of the Philippines )

Paranaque City

AFFIDAVIT OF LOSS

I, GRIMUALDO C. TRIVIÑO, of legal age, Filipino, and with residence

address at Putingbuhangin, San Juan, Batangas, after having been sworn
according to law, depose and state, that:

1. I was the owner/holder of Senior Citizen ID 24703 issued in San

Juan Batangas, on June 23, 2023. I used to keep said ID in my wallet.

2. On February 2, 2024 I went shopping at Galleria South in San Pedro,

Laguna. However, when I arrived home, I noticed that my Senior Citizen ID was
missing from my wallet. I exerted diligent efforts to find it, to no avail. It may
have fell off from my wallet when I paid my purchases. Considering the
circumstances narrated, I now consider said ID as lost and beyond recovery.

3. I execute this Affidavit to attest to the truth of the foregoing narration,

and to apply for the issuance of replacement Senior Citizen ID.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________, in Parañaque City, Philippines.

GRIMUALDO C. TRIVIÑO
Affiant

SUBSCRIBED AND SWORN TO before me this__________________ affiant

exhibited to me his DL N03-97-236546 2032,04.30.

Doc. No.______;
Page No.______;
Book No._____;
Series of 2024