Republic of the Philippines ]

Province of Bohol ]
Municipality of Carmen ] S.S.

AFFIDAVIT OF LOSS
(Re: Member Data Record)

I, ELENA B. OYANGORIN, Filipino, of legal age, married and a resident of

Katipunan, Carmen, Bohol, Philippines, after being duly sworn in accordance with law, hereby
depose and say:

1. That I am a holder of a Member Data Record (MDR) duly issued by the Philippine
Health Insurance Corporation (PhilHealth);

2. That said Member Data Record (MDR) got lost last 2022;

3. That I exerted diligent efforts to find and recover the aforesaid Member Data Record
(MDR), however, my efforts proved futile as until now, its whereabouts still could
not be ascertained, hence, I considered it to be lost for all intents and purposes;

4. That the said Member Data Record (MDR) was not transferred to any person for
consideration or used as collateral to secure obligations;

5. That I execute this affidavit voluntarily to attest to the truth of the foregoing
statements to support my request for the issuance of another Member Data Record
(MDR) in lieu of the lost one;

6. That further, I execute this affidavit for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto set my hand this 13th day of April, 2023 at
Carmen, Bohol, Philippines.

ELENA B. OYANGORIN
Affiant
ID No. 5847
Issued by the Office of the Senior Citizens Affairsp
Carmen, Bohol

SUBSCRIBED AND SWORN TO before me this 13th day of April, 2023 at Carmen,
Bohol, Philippines.