REPUBLIC OF THE PHILIPPINES)

CITY OF _____________ )S.S

x-------------------------------------------------x

JOINT AFFIDAVIT OF LOSS

We, AMALIA DELOS REYES RETOTAR AND FERDINAND M. RETOTAR, both of

legal age, married to each other and a resident of Brgy 36, Araniw, Laoag City, after having duly sworn
to in accordance with law, hereby depose and say that:

1. We are the holders of E-Cards. A GSIS cards issued to its members. And, I, Amalia
Delos Reyes Retotar, is a holder of a PhilHealth card which was issued this year.

2. That on November 25, 2019, the wife, Amalia Retotar, went to the Laoag City
Commercial Complex to purchase items for our household. While within the area, she
noticed that her wallet containing the above-stated E-Cards and PhilHealth card was
missing.

3. She exerted diligent efforts to locate the same but to no avail and we therefore considered
the same as lost and can no longer be found;

4. We are executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ______________ at _______.

AMALIA DELOS REYES RETOTAR FERDINAND M. RETOTAR

Affiant Affiant

SUBSCRIBE AND SWORN TO BEFORE ME this __________________ at

____________________, affiant having exhibited to me his ____________________.

Doc. No. ____;

Page no. ____;
Book No. ____;
Series of 2019.