REPUBLIC OF THE PHILIPPINES )

Province of Davao del Norte )S.S

City of Tagum )
x---------------------x

AFFIDAVIT OF LOSS

I, SHARAINE MAE D. SALAPAYNE, Filipino, of legal age, and a resident of Prk.

Pag-Asa, Manga, Visayan Village, Tagum City, Philippines, after having been duly sworn to in
accordance with the law, do hereby depose and say THAT;

1. I am the holder/owner/ possessor of a PhilHealth Member Identification Card,

ATM Card, Government I.D and LBC Card, which I had safely kept in my wallet together
with other personal effects;

2. Sometime in the morning of June 29, 2019, upon reaching home, I discovered that
said wallet was no longer found in my bag. I supposed there and then that the same must have
fallen along the way.

3. I now deem that my said wallet and its contents including the aforementioned
Government ID cards to have lost for all purposes and intents after the same was not located
despite diligent efforts;

4. That I am executing this Affidavit to attest to the truth and veracity of the foregoing
statements and to apprise the proper authorities concerned to facilitate the replacement of the
aforesaid identification cards and for whatever legal purpose/s this may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ at

_________________________, Philippines.

SHARAINE MAE D. SALAPAYNE

Affiant
I.D No: ______________________

SUBSCRIBED AND SWORN to before me this _________________at

________________________, Philippines.

Doc. No. ____

Page No. ____;
Book No. ____;
Series of ____.