REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S.

AFFIDAVIT OF LOSS
I, JUAN DELA CRUZ, of legal age, single, Filipino, with residence at
Quirino Street, La Loma, Quezon City, after having been sworn to in accordance
with law, hereby depose and say that:

1. I am a holder of a PhilHealth ID issued by the Philippine Health Insurance

Corporation in Fairview, Quezon City.

2. On 06 July 2020, while I was on board a taxi, on my way to Robinsons

Place, Padre Faura, Manila, I have with me a small black pouch
containing my PhilHealth ID, other small items, and coins. The small
pouch was placed inside my bag.

3. When I get off the taxi, I have still had my bag with me, but I was not
aware that my small pouch was no longer inside.

4. I just noticed that the small pouch was already missing when I was inside
the Robinsons Place and about to get the coins from my bag to pay the
item I bought.

5. I took earnest efforts to locate my pouch but to no avail. I suspect that it

must have fallen from my bag without me noticing it; hence, I gave up and
considered it as lost.

6. I execute this affidavit to attest to the truthfulness and veracity of the

foregoing facts, and for the purpose of securing another PhilHealth ID,
and for whatever purpose it may serve.

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

September 2020 in Quezon City, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of April

2024 in Pampanga, Philippines. Affiant exhibited to me his competent evidence
of identity as __________________.

Notary Public

Doc. No____;
Page No. ___;
Book No. ___;
Series of 2024.