REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAVITE ) S.S.

AFFIDAVIT OF LOSS
I, FERLY ROMEN NUESTRO, of legal age, Filipino, with address at 122
Tambo Ilaya, Indang Cavite after having been sworn to in accordance with law,
hereby depose and state, that:

1. I am in possession of my Unified Multi-Purpose Identification

(UMID) card and I used to put said card inside my wallet;

2. However while I was in Gen. Emilio Aguinaldo Memorial Hospital

in Trece Martires City unknown person stole said wallet together
with the said UMID card;

3. Despite diligent search and efforts to recover the said wallet and
UMID card the same can no longer be located;

4. I am executing this affidavit not for any unlawful purpose but for
any valid and legal purpose only.

IN TRUTH WHEREOF, I have hereunto affixed my signature this 11 th day of

April, 2019 at Alfonso, Cavite.

FERLY ROMEN NUESTRO

Affiant

SUBSCRIBED AND SWORN to before me this 11 th day of April, 2019 at

Alfonso, Cavite. Affiant exhibiting to me her PhilHealth ID no. 08-050904149-4

WITNESS MY HAND AND SEAL.

Doc. No. 149;

Page No. 31;
Book No. LXX;
Series of 2019.