REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA) S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, TONY BAÑAGA, of legal age, Filipino citizen, and a resident of Calitlitan,

Aritao, Nueva Vizcaya, after having been duly sworn to in accordance with law
hereby depose and state:

1. That I am holder of a PhilHealth Identification Card issued by PhilHealth,

Solano Branch in Solano, Nueva Vizcaya;

2. That the said PhilHealth Card has been in my possession. However last June
26, 2017, while I am on my way to Poblacion, Aritao, the said ID card has
been inadvertently lost and is now beyond recovery, notwithstanding diligent
efforts exerted to locate the same but to no avail.

3. That I attest to the veracity of the foregoing statements and hereby execute
this affidavit for the purpose of securing another plate in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto set my hand on this affidavit

this 3rd day of July 2017 at Bayombong, Nueva Vizcaya.

TONY BAÑAGA
Affiant
Driver’s License No: B0197028167

SUBSCRIBED AND SWORN TO before me this 3rd day of July 2017 at

Bayombong, Nueva Vizcaya.