REPUBLIC OF THE PHILIPPINES )

City of Puerto Princesa )SS.

AFFIDAVIT OF LOSS

I, Rachelle May Y. Gaite, of legal age, Filipino, and a resident of

Baranagay San Miguel, Puerto Princesa City, after having been sworn in
accordance with law, hereby depose and say:

1. That I am a holder of PhilHeath ID Card with ID no. 09-025515329-6

and Voter’s ID duly issued by the Commission on Election;

2. That, I used to put the said identification cards inside my wallet;

3. That, sometime on January 2019, when I arrived home from

attending a mass, I discovered that my wallet was no longer inside
my bag where my ID’s are placed;

4. That, despite diligent search and effort to locate said wallet, I could
no longer find it;

5. That, I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of said ID’s from
Philippine Health Insurance Corporation and Commission on
Election.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__________ of _________________ 2019, Puerto Princesa City.

RACHELLE MAY Y. GAITE

Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for

_____________________ this ____ day of _________ 2019. Affiant exhibiting before me
her PDAW ID with ID number 17-5316-008-057 issued by the City of Puerto
Princesa

Doc No.:________;
Page No.:_______;
Book No.:_______;
Series of 2019.