Republic of the
Philippines )
City of ________________ )
S.S
AFFIDAVIT OF LOSS OF PHILHEALTH CARD
I, (NAME OF AFFIANT), of legal age, Filipino,
single/married, and a resident of (Place of Residence), after
having been duly sworn to according to law hereby depose and state that:
1. I was a holder of a PhilHealth ID Card
No. _______________ issued in Cebu City;
2. Sometime on July 23, 2019, I went to the
M Lhuillier pawnshop branch in Banilad, Mandaue City, Cebu wherein after transacting
with the shop, I inadvertently left in the shop my wallet which contained the
said PhilHealth ID Card;
3. I only later discovered the loss of my
wallet, which contained the said PhilHealth card, that evening when I arrived at home;
4. I tried to contact the M Lhuillier
branch to seek my wallet but despite diligent search and efforts to locate the
said wallet containing my PhilHealth card, I could not find it such that I now
believe that it is now lost beyond recovery together with its contents;
5. Said lost card was not confiscated by
any officer of the law or agency by reason of any violation of any law,
ordinance, presidential decree or rules and regulation of said agency, and
neither was it given to any person;
6. As such, I am executing this Affidavit
of Loss to attest to the truth of the foregoing and for whatever legal purpose
it may serve.
IN WITNESS WHEREOF, I have hereunto set my
hand this (Date) at (Place), Philippines.
(NAME OF AFFIANT)
SUBSCRIBED AND SWORN TO BEFORE ME this (Date)
in the (Place), Philippines by (Name of Affiant) who presented her Senior
Citizen’s ID No. _____ issued on __________ at _____________, a government-issued identification card bearing her signature and photograph.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.
