Republic of the Philippines}City of Panabo…………………} S.S.x - - - - - - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I, QUINTIN B. ACDAL, of legal age, Filipino, married and a resident of Purok 2, Brgy. Katipunan, Panabo City, Davao del Norte, Philippines, after having been sworn to in accordance with law, do hereby depose and state THAT:

1. I was born on October 31, 1922 at Jagna, Bohol, Philippines;

2. I was issued a Senior Citizen Identification Card from the City Social Welfare and Development Office-Panabo City when I reached the age of Sixty (60) years old;

3. I usually place the above-mentioned Senior Citizen Identification Card inside my wallet for safe-keeping;

4. Sometime in the second week of March, 2016, the Senior Citizen I.D was no longer inside my wallet where I usually place it;

5. I immediately exerted efforts to look for it but my efforts proved futile since it was nowhere to be found, and may now be considered as LOST/MISPLACED;

6. I am executing this Affidavit to attest to the truth of the foregoing facts as requirement/s and for whatever legal purpose it may serve the premises.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of March 2016, at Panabo City, Davao del Norte, Philippines.

QUINTIN B. ACDALAffiant

CTC 00609513Issued On March 21, 2016

Issued At Panabo City

SUBSCRIBED AND SWORN to before me this 21st day of March 2016 at Panabo City, Davao del Norte, Philippines.

Doc. No. ____; Page No. ____; Book No. ____;Series of 2016.