REPUBLIC OF THE PHILIPPINES )

City of Imus ) S.S

AFFIDAVIT OF LOSS

I, CORAZON D. DELIVIOS, of legal age, Filipino, and residing at Blk 5 Lot 12

Quirino St. Villa Elisa Subd. Anabu II-E, City of Imus, Cavite after having been duly
sworn to according to law hereby depose and state:

1. I am a member of the Office of the Senior Citizen Association of Imus City

(OSCA);

2. Sometime on September 03, 2023, said Identification Card was misplaced

and got lost.

3. However, I was trying to locate the said Identification card but to my utter
disbelief, the same was nowhere to be found.

4. I am executing this affidavit to attest to the truth of the foregoing.

5. Further, I am executing this affidavit of loss for the replacement of the said
OSCA ID and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of October
2023 at the City of Imus.

Corazon D. Delivios
Affiant
Philippine Identification Card
Id No: 3106-1934-2182-0532

SUBSCRIBED AND SWORN to before me this 3rd day of October 2023 at the City
of Imus.

Notary Public

Doc. No.______
Page No.______
Book No._______
Series of 2023.