Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, CATALINA PERALTA NERI, 88 years old, Filipino citizen, and a
resident of Barangay Doclong 2nd, San Clemente, Tarlac, after having been
duly sworn to in accordance with law, do hereby depose and state THAT:

1. I am the daughter of the late CARINA SANTIAGO PERALTA

(Carina, for brevity) who died on October 22, 2016 at Barangay
Doclong 2nd, San Clemente, Tarlac at the age of 105;

2. During the lifetime of Carina, she is a member of the Senior Citizens

Affairs, San Clemente, Tarlac and was issued a Senior Citizen ID
Card;

3. Lately, when I was looking for the said ID card, I discovered that the
same was missing from the drawer of my mother where she used to
keep her personal effects. Thus, I searched all the possible drawers
and envelopes where the said ID Card might have been transferred
but it was in vain;

4. I am executing this affidavit to explain the surrounding circumstances

of the loss of the Senior Citizen ID Card of my mother Carina;

5. Finally, I am executing this affidavit to attest to the truth of the

foregoing statements and for all legal intents and purposes this may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of

June, 2017 at Camiling, Tarlac, Philippines.

CATALINA P. NERI
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited before me her Senior Citizen ID Card with
Control No. 2343 issued by the Office of the Senior Citizens Affairs, San
Clemente, Tarlac.

Doc. No.:_______;
Page No.:_______;
Book No.:_______;
Series of 2017.