REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE )SS.

MUNICIPALITY OF DAET )

AFFIDAVIT OF LOSS

I, FRANCIA D. BANDOLA, of legal age, married, Filipino, and a resident of Brgy. Ganado II, Biñan,
Laguna, 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) with and as such, I was
issued my own membership ID;

That I usually keep said PhilHealth ID inside my wallet together with other pertinent ID’s;

That however, recently, when I was sorting out for the said PhilHealth ID, I noticed that it was already
missing;

That diligent effort was exerted to retrieve my PhilHealth ID, but the same could not be recovered
anymore;

That said ID must have been misplaced and eventually lost while I was attending to my various personal
and business transactions during that time;

That I am executing this statement to attest to all the above facts, in support for my transactions at
Philhealth, to request for the issuance of a new PhilHealth ID in lieu of the lost one, and for whatever legal
purpose this may serve.

IN TRUTH WHEREOF, I have hereunto signed my name below, this 4 th day of March, 2011, in Daet,
Camarines Norte.

_______________________________
FRANCIA D. BANDOLA
Affiant

SUBSCRIBED AND SWORN to before me, this 4th day of March, 2011, in Daet, Camarines Norte.

Doc. No. 411

Page No. 83
Book No. LXIII
Series of 2011.