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Sample Affidavit of Loss PhilHealth ID
Sample Affidavit of Loss PhilHealth ID
AFFIDAVIT OF LOSS
I, JUAN DELA CRUZ, of legal age, single, Filipino, with residence at
Quirino Street, La Loma, Quezon City, after having been sworn to in accordance
with law, hereby depose and say that:
3. When I get off the taxi, I have still had my bag with me, but I was not
aware that my small pouch was no longer inside.
4. I just noticed that the small pouch was already missing when I was inside
the Robinsons Place and about to get the coins from my bag to pay the
item I bought.
Notary Public
Doc. No____;
Page No. ___;
Book No. ___;
Series of 2020.