REPUBLIC OF THE PHILIPPINES)

C I T Y O F M A K A T I ) S.S.

AFFIDAVIT OF LOSS LICENSE

I, ALBERT R. CAPON, of legal age, Filipino citizen, with residence address at

207 Sunrise Street, Barangay La Paz, Makati City, after having duly sworn to in
accordance with the law do hereby depose and say:

That I am the holder and in possession of the following items:

 GSIS UMID I.D.;

 Pag-IBIG Loyalty card;
 PHILHEALTH card, with I.D. No. 020505423063;
 Makatizen I.D.;
 MACEMCO ATM card;

That on 03 February 2022, at around 11:30 a.m., I discovered that my wallet

containing the said items was missing due to unavoidable circumstances beyond
knowledge;

That diligent effort has been made but futile therefore, considered it lost for all
intents and purposes;

That this affidavit is being executed to attest to the fact, to inform the proper
authorities concerned and for whatever legal purpose this may serve.

AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hand on this 05 th day of February 2022,

at Makati City, Philippines.

ALBERT R. CAPON
Affiant

SUBSCRIBED AND SWORN to before me on this 05th day of February 2022, at

Makati City, Philippines.

DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF 2022