REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, GINA T. LOMAAD, married, Filipino, with postal address at 44 Zenith Street, South Meridian Homes,
Salitran IV, Dasmariñas City, Cavite after having been duly sworn in accordance with law, hereby depose
and says, to wit:

1. That I am holder of the following Identification Card:

a. Auto Sweep RFID Card with account number 175361
2. That I had been keeping the said Identification Card in my wallet.
3. That I noticed that my wallet is missing last August 1, 2018.
4. That diligent effort to locate the same had proved futile.
5. That I am executing this instrument to attest to all the facts above and to request for a replacement
of the said Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hands this ___ day of November 2018 in the City of
Manila, Philippines.

GINA T. LOMAAD
Affiant

SUBSCRIBED AND SWORN before me this ___ day of August 2018 in the City of Manila, Philippines,
affiant exhibited to me his Community Tax Certificate No. ________ issued on at __________,
Philippines.

NOTARY PUBLIC

Doc No. ____;

Page No.____;
Book No. ____;
Series of 2018
REPUBLIC OF THE PHILIPPINES)
CITY OF MANILA ) S.S.
x-------------------------------------------x

AFFIDAVIT OF LOSS

I, GINA T. LOMAAD, married, Filipino, with postal address at 44 Zenith Street, South Meridian Homes,
Salitran IV, Dasmariñas City, Cavite after having been duly sworn in accordance with law, hereby depose
and says, to wit:

1. That I am holder of the following Identification Card:

a. Philhealth Membership Card with Philhealth No. 08-026219811-5
b. Voter’s Identification Card with precinct number 479B
2. That I had been keeping the said Identification Card in my wallet.
3. That I noticed that my wallet is missing last August 1, 2018.
4. That diligent effort to locate the same had proved futile.
5. That I am executing this instrument to attest to all the facts above and to request for a replacement
of the said Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hands this ___ day of November 2018 in the City of
Manila, Philippines.

JOHANNA GWENN T. LOMAAD

Affiant

SUBSCRIBED AND SWORN before me this ___ day of August 2018 in the City of Manila, Philippines,
affiant exhibited to me his Community Tax Certificate No. ________ issued on at __________,
Philippines.

NOTARY PUBLIC

Doc No. ____;

Page No.____;
Book No. ____;
Series of 2018