REPUBLIC OF THE PHILIPPINES)

_____________________________ ) SS.

AFFIDAVIT OF LOSS
(IDENTIFICATION CARDS)

I, _____________, Filipino, of legal age, and a resident of

_________________, after having been duly sworn in accordance with law, hereby
depose and say:

1. That I am a holder of a TIN identification card bearing No. 000 issued by

Bureau of Internal Revenue, PhilHealth identification card bearing No. 000
issued by Philippine Health Insurance Corporation, Voter’s identification card
bearing No. 000 issued by Commission on Election and Social Security
System identification card bearing No. 0000 issued by SSS;

2. That I used to put the above-named identification cards in my pouch;

3. That sometime on April 27, 2019, when I arrived home from work, I
discovered that all the identification cards named above was no longer in my
pouch where I used to place it;

4. Despite diligent search and efforts to locate said document, I could not find
it;

5. That said ID cards was not confiscated by the authorities by reason of any
violation of any rules and regulations;

6. That I am executing this affidavit to attest to the truth of the foregoing facts
and to request for replacement of my TIN identification card from the
Bureau of Internal Revenue, PhilHealth identification card from the Philippine
Health Insurance Corporation, Voter’s identification card from the
Commission on Election and Social Security System identification card from
the SSS.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of

____________ 20___ at ____________, Philippines.

_____________________________
Affiant