REPUBLIC OF THE PHILIPPINES )

CITY OF DASMARIÑAS, CAVITE )S.S

X---------------------------------------------X

AFFIDAVIT OF LOSS
I, VIRGINIA M. DINA, of legal age, Filipino citizen, single and residing at blk.7, Lot 89,
Lakersfield Subd., Toclong, Kawit, Cavite, after being duly sworn to in accordance with
law, despose and state: That - -

1. That I am a holder of Senior Citizen ID issued in Kawit, Cavite;

2. Recently however said Senior Citizen ID got lost, misplaced and/or Missing and
despite diligent efforts I could not locate the same from the files of my
important belongings;
3. That I have not given said to any person or entity of an illegal or unlawful
purpose;
4. That for all intents and purposes I hereby declare under oath that the
aforesaid Senior Citizen ID and lost beyond recovery;
5. That I am executing this affidavit to attest to the truth and veracity of the
foregoing statements and for whatever legal purpose the same way serve
best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 25th day of June
2019 in City of Dasmariñas, Cavite.

VIRGINIA M. DINA
Affiant

SUBCRIBED AND SWORN to before me this 25th day of June 2019 in City of Dasmariñas,
Cavite affiant exhibiting to me his PhilHealth ID card No. 19000516400-5 Issued by PhilHealth
Imus, Cavite.