REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )
CITY/MUNICIPALITY OF SAN PEDRO ) S.S.

AFFIDAVIT OF LOSS

I, ________________, of legal age, Filipino, married, and a resident of

________________________________, after having been duly sworn to in accordance with law,
depose and state that:

1. I am a holder of the following: Philhealth ID, Pag-Ibig ID, SSS ID, BPI
Savings Account ATM, Petron-BPI Mastercard, BDO Savings Account ATM,
and Maxicare ID which were all placed inside my wallet;

2. On 13 April 2017, I was driving to Lucena City via San Juan Batangas.
I stopped and alighted in San Juan, Batangas to buy clay pots and
proceeded driving. After an hour drive I stopped by at a Dunkin Donut outlet
to buy something to eat but I noticed that my wallet is already missing. It
must have been lost when I was making my purchase at the clay pot store in
San Juan, Batangas;

3. Despite diligent search and efforts to locate my wallet containing said

IDs and cards, I could not find it such that I believe that they are now lost
beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts

and to support my application for the issuance of new Philhealth ID, Pag-
Ibig ID, SSS ID, BPI Savings Account ATM, Petron-BPI Mastercard, BDO
Savings Account ATM, and Maxicare ID in lieu of those which were lost;

5. Affiant further sayeth naught.

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

__________________ 2018 in San Pedro, Laguna, Philippines.

________________________
<NAME>
Affiant

SUBSCRIBED AND SWORN to before me this ______ day of __________________ 2017

in San Pedro, Laguna, affiant exhibiting to me a copy of his PAG-IBIG ID with No.
_____________________.

Notary Public

Doc No. ___

Page No.___
Book No. ___
Series of 2018