REPUBLIC OF THE PHILIPPINES

PROVINCE OF TARLAC
MUNICIPALITY OF LA PAZ

AFFIDAVIT OF LOSS

I, JOANA GOMEZ UMALI of legal age, married, Filipino citizen, and a

resident of San Roque, La Paz, Tarlac after being sworn in accordance with the law
depose and say:

1. I am a holder of a Philhealth Identification Card issued by Philippine Health

Insurance Corporation;

2. The foregoing Philhealth Identification Card was lost on August 22, 2019
because my wallet was drop/loss:

3. That despite diligent efforts has been exerted in order to find and locate the
said Philhealth Identification Card; the same could no longer be found and
proved to be beyond recovery;

4. That this affidavit it was executed to attest the truth of the foregoing and for
purposes of the re-issuance of a new Philhealth Identification Card in my
favor and whatever purposes it may serve best.

IN WITNESS WHEREOF, I have here unto set my hand this 30h day of
October, 2019 in the Municipal of La Paz, Province of Tarlac.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me, this 30th day of October 2019,
by JOANA GOMEZ UMALI, who exhibited to me (his/her) ID issued by,
Barangay Identification Card with ID No. S.N. : 2019-346 issued at San
Roque La Paz, Tarlac Philippines on Oct. 30, 2019

Doc No.: 52
Page No.: 11
Book No.: 1
Series of: 2019