Republic of the Philippines )

Camiling Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, BRIGETTE NAVARRO y BAUTISTA, of legal age, Filipino
citizen, single and a resident of Paterno St., Poblacion D., Camiling,
Tarlac, Philippines, after having been duly sworn to in accordance with
law, do hereby depose and state THAT:

1. I am a member of the Philippine Health Insurance Corporation

(PhilHealth) and I was issued an identification card which I usually
keep inside my wallet;

2. Lately, when I was organizing the contents of my wallet, I

discovered that my PhilHealth ID card was missing. I tried to look
for it in my other wallets but I did not find the same. Also, I asked
my household members if they have seen it but all answered in the
negative;

3. All the diligent efforts exerted to locate my PhilHealth ID proved

futile; hence, I now consider the same as lost and beyond recovery;

4. My PhilHealth ID Card was never used as a security to any

obligation;

5. I am executing this affidavit to attest to the truth of the foregoing

statements and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this 4th

day of July, 2017 at Camiling, Tarlac, Philippines.

BRIGETTE NAVARRO y BAUTISTA

Affiant

SUBSCRIBED TO AND SWORN to before me on the date and

place indicated above. Affiant exhibited to me her Police Clearance with
control no. 20170118026 issued by the Philippine National Police of
Camiling, Tarlac, Philiipines.

Doc. No.:________;
Page NO.:________;
Book No.:________;
Series of 2017.