REPUBLIC OF THE PHILIPPINES)

City of Davao) S. S

AFFIDAVIT OF LOSS

I, TAWGAN TIYAYA GOZO, Filipino, of legal age, married and a resident of Purok 1 Sitio
Uyanguren Barangay Tigatto Buhangin District Davao City,Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

1 That I am already Sixty-EIGHT (68) years of age, which in effect a bona fide member
of the Senior Citizen Organization of Mandaue Cityand consequently was issued a Senior Citizen
Identification Card;

That sometime on the last week of March 2015, while I was inside RosePharmacy in Tabok, Mandaue
City, the same Senior Citizen IdentificationCard was lost without my knowledge;

That despite diligent search and efforts to locate my Senior CitizenIdentification Card, I could not
recover the same such that I nowbelieve that it is now lost beyond recovery;

That said Senior Citizen Identification Card has not been confiscated byany government agency or by any
private individual;

As such, I am executing this Affidavit of Loss to attest to the truth ofthe foregoing and for whatever legal
purpose this affidavit may serve.

IN WITNESS WHEREOF,
I have hereunto set my hand this 15 April 2015at Mandaue City, Philippines.

NARCISA PURGATORIO GUIDO

AFFIANT

SUBSCRIBED AND SWORN

to before me, this 15 April 2015, by Affiant,

NARCISA PURGATORIO GUIDO,

who exhibited her COMELEC VIN: 2230-0406A-J2946NPG20000 and to me known to be the same
person who personally signed theforegoing Affidavit of Loss.Doc. No. ______;Page No. ______;Book
No.______;Series of 2015.