Republic of the Philippines)

Cebu City…………………) S.c.

AFFIDAVIT OF LOSS

I, ___________________________, of legal age, Filipino, single and a

resident of Gorordo Avenue, Lahug, Cebu City, after having been duly
sworn to in accordance with law, do hereby depose and state that—

1. I am a member of Philippine Health Insurance Corporation

(PhilHealth) to which I have been issued a membership
identification card;

2. Recently, I was able to buy a new wallet and I decided to transfer

all my important personal belongings from my old wallet to the
new one;

3. However, I noticed that my PhilHealth identification card was no

longer among those cards that I transferred;

4. I searched for the said card even in the cabinet box, however,
said effort proved futile;

5. I am declaring said identification card to have been lost for all

intents and purposes;

6. I am executing this affidavit to attest the truthfulness of the

foregoing and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

24th day of March 2021 in the City of Cebu, Philippines.

_____________________________
Affiant
Valid ID _____________________
Valid until ___________________

SUBSCRIBED AND SWORN TO before me this 24 th day of March in

the City of Cebu, Philippines.

Doc. No. __
Page No. __
Book No. __
Series of 2021