Republic of the Philippines )

____________,_____________ ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, _________________________-, of legal age, Filipino, single, and a resident of

_________________________________________, after having been sworn in accordance with
law, hereby deposes and states the following:

1. I am holder/owner/ or possessor of the following identification document:

 PhilHealth Identification Card (ID)

2. I have recently discovered the said item/s 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
(Signature over Printed Name)

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. _____
Series of 2021