Republic of the Philippines )

City of Manila ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, Arnel T. Taruc Jr. of legal age, Filipino, single, and a resident of

1020 park avenue mansion, after having been sworn in accordance with law, hereby deposes
and states the following:

1. I am possessor of the following identification card Philhealth I.D.

2. I have recently discovered the said item is irretrievably lost and can no longer be
found despite diligent efforts to locate the same;

3. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant

Arnel T. Taruc Jr.

Competent Evidence of Identity
ID: Philhealth
issued on: January 23, 2020
at: philhealth office

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The
affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public
Doc. No.
Page No.
Book No. I
Series of