REPUBLIC OF THE PHILIPPINES )

City of Roxas ) S.S.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, MERLY P. HIMAN, Filipino, of legal age, married and a

resident of Brgy. Pob. Takas, Cuartero, Capiz, after having
been duly sworn in accordance with law, hereby depose and
state:

1. That I am a holder of a TIN Identification Card

bearing TIN No.914-542-280 issued by Bureau of
Internal Revenue;

2. That the said TIN Identification Card was lost in

my possession and its whereabouts could not be
ascertained;

3. That diligent effort to locate and search in places

where I have been on that day I lost it; however said
TIN ID Card was nowhere to be found;

4. That said TIN ID Card was not confiscated by the

authorities by any reason. Neither I violated any
rules and regulations;

5. That I am executing this affidavit to attest to the

truth of the foregoing facts and to request for a
replacement of said TIN Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand

this 17th day of December, 2019 at the Roxas City,
Philippines.

MERLY P. HIMAN
PhilHealth ID No. 19-
000649119-0

SUBSCRIBED AND SWORN to before me this 17th day

of December 2019, in the City of Roxas, Philippines. I further
CERTIFY that I have personally examined the affiant, and I
am fully satisfied that he voluntarily executed the foregoing
Affidavit, and he read and understood the contents thereof.