(Republic of the Philippines )

City of Zamboanga . . . . . . . . ) s.s.

x. . . . . . . . . . . . . . . . . . . . . . x )

AFFIDAVIT OF LOSS

I, Mcdonalds, of legal age, single , Filipino and a resident of San

Roque, Zamboanga City, Philippines, under oath, deposed and
state, that:

I am a bonafide member of Philippine Health Insurance

Corporation with PIN14-050212512-1;

That recently, the said identification card got lost from my

possession, probably it was misplaced or fell somewhere without my
knowledge;

Diligent effort was exerted to locate the card but to no avail.

Hence, the same is now considered lost beyond the point of
recovery; and

I am executing this affidavit to attest to the veracity of the

foregoing facts and to whatever legal purposes this may serve under
the law;

IN WITNESS WHEREOF, I have set my hand this 21st day of

February 2020 in Zamboanga City, Philippines.

Mcdonalds
Affiant

SUBSCRIBED AND SWORN TO before me this day 21st day of February

2020 in Zamboanga City, Philippines.

Doc. No. ___;

Page No. ___;
Book No. 203;
Series of 2020.