REPUBLIC OF THE PHILIPPINES)

CITY OF CAGAYAN DE ORO ) S. S.

AFFIDAVIT OF LOSS

I, EDNA Q. SAMPANG, 55 years old, married and a resident of

Macanhan, Carmen, Cagayan de Oro City, after having been duly sworn to an
oath in accordance with law, hereby depose and say, that:

1. My mother, PRICIOSA G. QUIJADA, 89 years old and a widow, was

issued an Office of the Senior Citizen Affairs (OSCA) identification
card by the OSCA - Cagayan de Oro Chapter, Cagayan de Oro City;

2. The said OSCA card was entrusted by my mother to my possession,

and the same had been in my possession and custody until February
2015 when I inadvertently lost the said identification card when I left
my wallet that contained the OSCA card, among others, at the DV-
Soria area of Cagayan de Oro City;

3. Earnest efforts were exerted by me in locating the said OSCA card,

however all efforts proved futile for the same was not located and it
is now beyond recovery; and

4. This Affidavit is executed to attest to the truth of the foregoing

statement, and to support the application of my mother for an
issuance of a new Senior Citizen Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my

signature this 12th day of September, 2015, at Cagayan de Oro City, Philippines.

EDNA Q. SAMPANG
Affiant

SUBSCRIBED AND SWORN to before me on the date and place above-

written by the Affiant who exhibited to me her identification card –
ZAMCELCOID Card No. 204829-003.