Republic of the Philippines)

City of Cebu )S.S

AFFIDAVIT OF LOSS

I, ALBERT EDILBERT PANULAYA GOMEZ, of legal age, Filipino, single, and

resident of Babag, Lapu-Lapu City, Philippines, after having been duly sworn in
accordance with law, hereby depose and state:

1. That I was duly issued a SSS Identification Card with SSS no. 33-4619192-6 by
Social Security System (SSS);

2. That sometime on September 2, 2022, around 5:00 pm, I was having an errand
and I kept the above-mentioned item inside my wallet for safe keeping and
easy access;

3. However, after arriving at home, I noticed that my wallet wherein the

abovementioned item kept were already missing and it might have
accidentally fallen out from my pocket;

4. That, nevertheless, I still tried to search for said SSS ID in on all the possible
places it could be and even re-traced my steps, all to no avail;

5. That after exerting my utmost effort in locating said SSS ID and still failing to
locate it, I am constrained to believe that it is lost beyond recovery;

6. I am executing the instant Affidavit to attest the veracity of the forgoing

statements and for whatever legal purpose this may serve best;

IN WITNESS WHEREFORE, We have hereunto affixed our signature this 5th day of
September, 2022, at Cebu City, Philippines.

ALBERT EDILBERT PANULAYA GOMEZ

Affiant
12-050785232-2
PhilHealth

SUBSCRIBED AND SWORN to before me, a notary public for and in the City of
Cebu, this 5th day of September, 2022 at Cebu City; affiant who personally appeared
before me with their competent evidence of identity above, and who signed this
instrument in my presence, and avowed under the penalty of law to the whole truth
of its contents.

WITNESS MY HAND AND SEAL on the date and at the place above-written.

Doc.No._____;
Page No.____;
Book No.____;
Series of 2022.