REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S.S.

Municipality of Prosperidad )
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AFFIDAVIT OF LOSS

I, ROSELYN P. SARIGNAYA, Filipino, of legal age, and a resident Purok 7, Pasta, San
Francisco, Agusan del Sur, after being duly sworn to in accordance with law, hereby depose and
state:

That I am the same person executing this Affidavit;

That I am a beneficiary of Pantawid Pamilyang Pilipino Program (4Ps) of Department

of Social Welfare and Development (DSWD ;

That being a beneficiary of 4Ps, I was issued a 4Ps Identification (ID) Card;

That I used to keep the above 4Ps ID inside my document folder in our home in Purok 7,
Pasta, San Francisco, Agusan del Sur;

That it was only last month that I searched for the said ID, for the release of cash card, but
I could no longer find the same;

That despite diligent search and efforts to locate my 4Ps ID, the same could not be found
such that I now consider it lost beyond recovery;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
request the DSWD to issue a new 4Ps ID in lieu of the one lost, and for the release of
cash card to me.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of February 2019
at Patin-ay Prosperidad, Agusan del Sur;
.

ROSELYN P. SARIGNAYA
Affiant
VIN 0308-0062A-B2869RPS20000

SUBSCRIBED AND SWORN to before me, this 19th day of February 2019 at Patin-ay
Prosperidad, Agusan del Sur;