REPUBLIC OF THE PHILIPPINES)

CITY
OF
MANDAUE) S.S.

AFFIDAVIT OF LOSS

I, XAVIER NN F. ANGUSAN, of legal age, Filipino, single and a resident of

Sta. Cruz, Guizo, Mandaue City after having been duly sworn to in accordance
with law, hereby depose and state that:

1. I was issued a PhilHealth ID, SSS ID and Taxpayers Identification

Number ID;
2. Last January 14, 2016, my boarding house was targeted by robbers,
and in the course of the said robbery, my wallet, containing the
aforementioned IDs, was taken;
3. Despite earnest efforts to locate the whereabouts of the abovementioned cards, it could not be found and retrieved. As such, I
believe that the said IDs are lost beyond recovery;
4. I am executing this affidavit to attest to the veracity of the foregoing
statements, and in compliance with the requirements for the issuance
of another PhilHealth ID, SSS ID and TIN ID, and for whatever legal
purposes it may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 15 th
day of January 2016 at Mandaue City, Philippines

XAVIER NN F. ANGUSAN
Affiant
CTC No. 08580125

SUBSCRIBED AND SWORN TO before me this 15 th day of January 2016

at Mandaue City, Philippines, affiant being personally known to me and
exhibiting his CTC No. as shown above.

Doc No. ________

Page No. _______
Book No._______
Series of 2016.