Republic of the Philippines )

Province of Southern Leyte ) s.s.

Municipality of Tomas Oppus )
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AFFIDAVIT OF LOSS

I, CATHERINE UDARBE TAMBIS, of legal age, married, Filipino Citizen

and a resident of Brgy. San Roque, Tomas Oppus, Southern Leyte, Philippines,
after having been duly sworn to in accordance with law, hereby voluntarily
depose and state:

That I am a holder of a Bureau of Internal Revenue (BIR) Card which

contains my Taxpayer’s Identification Number, 293-639-947, issued by the BIR, ;

That I always put the said BIR card in my wallet, together with other
documents in my possession;

That sometime in January 2018 the said wallet was lost and nowhere to
be found;

That I exerted efforts to locate the same but to no avail;

That my BIR Card has never been confiscated nor apprehended for any
violation of the law; and

That I am executing this affidavit to attest to the truth of the foregoing

facts and for whatever lawful purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of October
2018 in the Municipality of Tomas Oppus, Southern Leyte, Philippines.

CATHERINE UDARBE TAMBIS

Affiant
PHILHEALTH NO: 12-025540749-5

SUBSCRIBED AND SWORN to before me this 9th day of October 2018 at

Tomas Oppus, Southern Leyte, Philippines.