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AFFIDAVIT OF LOSS
I, FRANCIA D. BANDOLA, of legal age, married, Filipino, and a resident of Brgy. Ganado II, Biñan, Laguna, after having been sworn on oath in accordance with law hereby voluntarily depose and say: That I am a member of the Philippine Health Insurance Corporation (PhilHealth) with and as such, I was issued my own membership ID; That I usually keep said PhilHealth ID inside my wallet together with other pertinent ID·s; That however, recently, when I was sorting out for the said PhilHealth ID, I noticed that it was already missing; That diligent effort was exerted to retrieve my PhilHealth ID, but the same could not be recovered anymore; That said ID must have been misplaced and eventually lost while I was attending to my various personal and business transactions during that time; That I am executing this statement to attest to all the above facts, in support for my transactions at Philhealth, to request for the issuance of a new PhilHealth ID in lieu of the lost one, and for whatever legal purpose this may serve. IN TRUTH WHEREOF, I have hereunto signed my name below, this 4th day of March, 2011, in Daet, Camarines Norte.
_______________________________ FRANCIA D. BANDOLA Affiant
SUBSCRIBED AND SWORN to before me, this 4th day of March, 2011, in Daet, Camarines Norte. Doc. No. 411 Page No. 83 Book No. LXIII Series of 2011.