Republic of the Philippines )

City of CALOOCAN ) S.S.

AFFIDAVIT OF LOSS
I, ALLAN M. ANTONIO, of legal age, married, and a resident of 309 NHC Road, Tala
Caloocan City, after being duly sworn according to law, do hereby depose and state that:

1. Sometime on 31 August 2023, while on my way home and while riding my

motorcycle, my wallet fell and it contained the following documents:
a. SSS
b. PWD IS
c. Professional Driver’s License issued by LTO East Avenue
d. National ID
e. Gcash ATM Card
f. Metrobank ATM

2. The aforementioned Gcash is registered under mobile no. 09383452407.

3. Despite diligent search and best efforts, I failed to locate and recover the said wallet
which contains the abovementioned IDs to this day;

4. Wherefore, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and for whatever legal purposes that this may serve;

WITNESS WHEREOF, I have hereunto affixed my signature this ________________ at

______________________ City, Philippines.

_____________________________
ALLAN M. ANTONIO
Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for CALOOCAN
City this________________________.

The affiant, whom I identified through the following competent evidence of identity:
Philhealth No. 19-089726812-8 issued by Philhealth personally signed the foregoing
instrument before me and vowed under penalty of law to the whole truth of the contents of
said instrument.

Doc. No. __________

Page No. __________
Book No. __________
Series of 2023.