REPUBLIC THE PHILIPPINES)

BATANGAS CITY ) S.S.

AFFIDAVIT OF LOSS

I, TIMOTEO M. MANIBO, married, of legal age, Filipino, and a resident

of Mainaga, Mabini, Batangas, after having been duly sworn to in accordance
with law, hereby depose and state that:

[1] I am a holder of a GSIS eCard, issued by the Office of the

Government Service Insurance System (GSIS);

[2] Recently, while I was searching for the said item, I have discovered
that the same was lost;

[3] I exerted diligent efforts to find and locate the said item but the
same proved futile;

[4] Moreover, said item has not been returned to me;

[5] I am executing this affidavit to attest to the truth of all the

foregoing facts, to inform the proper authorities and for whatever legal purpose
this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 09 May

2018, at Batangas City.

TIMOTEO M. MANIBO
Affiant
PhilHealth ID No. 08-000047061-2

SUBSCRIBED AND SWORN TO BEFORE ME this 09 May 2018, at

Batangas City, affiant, personally known to me, exhibiting to me his Identification
card with number stated above.

SONNY JOSE M. RICABLANCA

Notary Public
Until 31 December 2018
PTR No. 3022119 01-03-18 Batangas City
Doc. No. ____; IBP No. 1065629 Batangas City
Page No. ____; Roll No. 69544 Serial No. 2017-20
Book No. ____; MCLE Exempted, pursuant to MCLE Governing
Series of 2018. Board Order No. 1, S.2008
Zenaida Arcade, 43 M.H. del Pilar St., Batangas City