REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SURIGAO DEL SUR) s.s.

CITY OF TANDAG…………………..)

AFFIDAVIT OF LOSS

I, CONSORCIO BONGABONG y AVILA, Filipino, 77 years old,

widower and a resident of Poblacion, Cagwait, Surigao del Sur, Philippines,
after having been duly sworn to in accordance with law, depose and state:

1. That I am a holder of the following identification cards:

PhilHealth ID Card issued by the Philippine Health Insurance

Corporation-Tandag City;
SSS Card issued by the Social Security System-Tandag City
Voter’s ID Card issued by the Commission on Elections- Cagwait,
Surigao del Sur.

2. That on April 5, 2013, my wallet containing the aforesaid ID cards was

lost and its whereabouts cannot anymore be ascertained despite
diligent search;

3. That I am executing this Affidavit of Loss to attest to the veracity of the

foregoing and in support of my application for the issuance of another
ID Card from the Office of the PhilHealth, SSS and COMELEC .

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18 th

day of April, 2013 at Tandag City, Surigao del Sur, Philippines.

CONSORCIO A. BONGABONG
AFFIANT

SUBSCRIBED AND SWORN TO before me this 18TH day of APRIL,

2013 at Tandag City, Surigao del Sur, Philippines. The identity of the affiant
is established by his Senior Citizen ID Card with No. 1483 issued by Office of
the Senior Citizen Affairs, Cagwait, Surigao del Sur on April 18, 203.