Republic of the Philippines )

City of Quezon ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, ___________, of legal age, Filipino, single/married, and a resident of 3G, TOWER

4,__________________., after having been sworn in accordance with law, hereby deposes and
states the following:

1. I am holder/owner/ or possessor of the following identification card / document:

FRIENDLYCARE’S FRIENDLY CARD (FAMILY HEALTH SAVER), which I availed at P.
Tuazon, Cubao Branch last August 2019.

2. I have recently discovered the said item/s is irretrievably lost and can no longer be found
despite diligent efforts to locate the same;

3. In the event that the lost card should hereafter be found or located, I undertake to forward or
surrender the same FriendlyCare Clinic, Cubao Branch for appropriate disposal.

4. I am executing this affidavit to attest to the truthfulness of the foregoing facts and for what
legal intents and purposes it may serve.

Affiant

Personally came and appeared before me this _22nd_ day of October 2019, at Quezon City,
with Government Issued ID ____________ _, known to me and to me known to be the same
person who executed the foregoing instrument, and acknowledged that the same is his/her free
act and voluntary deed.

WITNESS MY HAND AND SEAL, at the place and on the date first above written.

NOTARY PUBLIC

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.