Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, NOEL S. CLAUD, Filipino, single, of legal age, resident of Barangay San Santiago
Malvar, Batangas, Philippines, after having been sworn by law hereby depose and state
that:

1. I am the owner of an ATM Card issued by the RCBC and Philhealth ID;

2. Sometime on June 22, 2024, Saturday, in Lipa City, I lost the above ATM Card and
Philhealth ID which were snatched by a bad person under the following circumstances:

3. despite diligent efforts exerted, I could not locate or recover the said ATM card and
Philhealth ID, and to the best of my knowledge, the same is truly lost;

4. The said ATM Card and Philhealth ID have not been confiscated by any officer of the
law or the issuing agency or office due to the violation of any law, statute, order, rule, or
regulation;

5. If the lost ATM card and Philhealth ID should hereafter be found or located, I undertake
to forward or surrender the same to the company where I worked for appropriate disposal;

6. I am executing this affidavit to attest to the truth of the foregoing and to request the
issuance of a new ATM card and Philhealth ID to replace the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th of June, 2024, in Malvar,
Batangas, Philippines.

NOEL S. CLAUD
Affiant
Issued ID: Company ID
ID No. 23-09458

SUBSCRIBED AND SWORN to before me on this 24th day of June 2024, in Malvar,
Batangas Philippines.

Doc. No. ;
Page No. ;
Book No.
; Series of 2024.