AFFIDAVIT OF LOSS

Republic of the Philippines

Province of Pangasinan
City of Dagupan

I, , of legal age, Widow, residing at B, Pangasinan after being sworn in

accordance with law, depose and say;
That I am the owner of different IDS issued by the gov’t., like my TIN ID, SSS
ID and Phil Health ID.

That I placed said IDs in a Wallet inside my bag everytime I go out.

That said IDs were lost which I believed taken by snatchers inside my bag.

That said IDs are now beyond recovery.

IN WITNESS WHEREOF, I have here unto set my hand this ____ day of
December 2022 in the City of Dagupan, Province of Pangasinan.

Signature of Affiant

TIN 128-344-000

Signed in the presence of:

____________________ ____________________

REPUBLIC OF THE PHILIPPINES)

DAGUAPAN CITY, PANGASINAN) S.S.

BEFORE ME, personally appeared the party who is made known to me to be

the same person who executed the foregoing instrument and acknowledged to
me that is her free act and deed.
WITNESS MY HAND AND SEAL on the date and in the place above written.
Doc. No. _______
Page No. _______
Book No. _______
Series of _______