REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE )SS.

MUNICIPALITY OF D A E T )

AFFIDAVIT OF LOSS
I, JULIANA E. ABARCA, of legal age, married, Filipino citizen, and a resident of Purok 5, Brgy.
Alawihao, Daet, Camarines Norte, after having been sworn on oath in accordance with law hereby
voluntarily depose and say:

That I am a member of the Philippine Health Insurance Corporation (PhilHealth), and as such I was
issued my own PhilHealth ID bearing No. 10-2008989793;

That when not being used, I usually place said ID inside a file drawer in my house for safekeeping
together with my other pertinent documents and IDs;

That however, sometime in March, 2010, I discovered that said ID was already missing from the
drawer;

That likewise included with the ID is the original copy of the Certification of membership or (PHIC)
Form CE 1 issued by PhilHealth Camarines Norte Service Office;

That diligent efforts were exerted to locate said PhilHealth ID and PHIC Form CE 1, but to no avail;

That I am executing this statement to attest to all the above facts, in support for my transactions at the
Philhealth, to request for the issuance of a new PhilHealth ID and/or PHCI Form CE 1 if applicable, in lieu
of the lost ones, and for whatever legal purpose this may serve.

IN TRUTH WHEREOF, I have hereunto signed my name below, this 9 th day of July, 2010, in Daet,
Camarines Norte.

__________________________
JULIANA E. ABARCA
Affiant

SUBSCRIBED AND SWORN to before me, this 9th day of July, 2010, in Daet, Camarines Norte.

Doc. No. 430

Page No. 86
Book No. LVII
Series of 2010.