Republic of the Philippines)

Province of Pangasinan )
Municipality of Villasis ) s.s.

AFFIDAVIT OF LOSS

I, MILDRED TOMAS y TORRES, of legal age, single, Filipino citizen and

a resident of Brgy. San Antonio, Sto. Tomas, Pangasinan, after having been duly
sworn to in accordance with law, hereby depose and state that:

1. That I was issued a Company Identification Card by Magic Group of

Companies Magic Grocery, Villasis, Pangasinan Branch;

2. That I keep the said Identification Card inside my bag for safe keeping;

3. However, last December 21, 2016 when I check the said Company
Identification Card which I put inside my bag, I found out that it was
missing, I might misplace the same;

4. I exerted diligent efforts to locate said Company Identification Card but to

no avail, thus, it is now considered loss and beyond recovery;

5. I am executing this affidavit to attest to the truthfulness of the foregoing

statements and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 22 nd day of

December 2016 at Villasis, Pangasinan.

MILDRED TOMAS y TORRES

Affiant
Philhealth ID Card No.05-251927656-9

SUBSCRIBED AND SWORN to before me on the date and place above

written. Affiant personally appeared and declared that she voluntarily executed,
read, and understood her statements to be true based on her personal
knowledge.