AFFIDAVIT OF LOSS

I, ______________________, of legal age, ______________

Filipino citizen, with residence and postal address at
______________________, after having been duly sworn to an oath
in accordance with law, do hereby depose and say, that:

1. I am a bonafide member of the Philippine Health Insurance

Corporation and as such, I was issued a Philhealth
Identification Card;

2. I usually keep the said ID inside my wallet along with

purchase receipts and other IDs for convenience and
safekeeping;

3. ____________________, when I looked for the said wallet

containing the said Philhealth Identification Card, I could
not find the same;

4. Despite diligent efforts in searching for it everywhere, I

still could not find the said wallet;

5. I hereby declare that my wallet and the PhilHealth

Identification Card I stored in it is irretrievably lost;

6. I am executing this affidavit to attest to the truth of the

above-stated facts and in compliance with the requirements of
the Philippine Health Insurance Corporation in regard to my
application for a replacement Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________________, in the
___________________________, Philippines.

______________________________
Affiant

-OATH-
Republic Of The Philippines)
City Of . . . . . . . . . . )S.S.
X - - - - - - - - - - - - X)
SUBSCRIBED AND SWORN to before me this
_______________________, exhibiting competent evidence of his
identity through his _____________________ issued by the
______________________________________, Philippines.