REPUBLIC OF THE PHILIPPINES )

) S.S.
x-----------------------------------------------x
AFFIDAVIT OF LOSS
I, Edward P. Bartolome, of legal age, Filipino, single, and
a resident of 2448 La Torre Street, Sta. Ana, Manila after having
been duly sworn to in accordance with law, depose and
state that:
1. I am a holder of a Person With Disability Identification
(PWD ID) Card no. 1339140742 issued on 29 September
2014 at Paco, Manila.
2. Sometime on 20 April 2015, my PWD ID card was
misplaced and got lost.
3. Efforts were exerted to locate my PWD ID, but in spite of
diligent search, it could not be found and the same is now
beyond recovery.
4. As such, I am executing this Affidavit of Loss to attest to
the truth of the foregoing and to support my application
for the issuance of a new PWD ID card.
IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in ________________________.
_______________________
Edward P. Bartolome
Affiant
SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in _________________, , affiant exhibiting to
me her
competent
evidence
of
identity
by
way
of
______________________________
issued
at
______________
on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2015