REPUBLIC OF THE PHILIPPINES )

Province of Negros Oriental )

City of Dumaguete )S.S.
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AFFIDAVIT OF LOSS

I, CATHERINE SILVA, of legal age, Filipino, married, and a resident of

Agan-an, Sibulan, Negros Oriental, after having been sworn in accordance with
law, hereby deposes and states the following:

1. That I am the owner of several government issued ID cards namely, my

current Driver’s License bearing no. G02-07-05392, PhilHealth ID, and
SSS ID.

2. That I had head surgery sometime in March 2019.

3. That during and after my surgery, my husband was in possession of the

said ID cards and used the same in transactions involving myself.

4. That somewhere along these transactions, the said ID cards may have
been left or misplaced.

5. That I exerted all efforts to locate the same but to no avail, and thus I am of
the firm belief that they are now lost beyond recovery.

6. That the said Driver's License has not been confiscated by the LTO, Police
or other Traffic Enforcers for any traffic violation; neither were the
PhilHealth ID and SSS ID given as security for any obligation.

7. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the issuance of a new Driver’s
License card, PhilHealth ID card and SSS ID card.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of

October 2019 at Dumaguete City, Philippines.

CATHERINE SILVA
Affiant
COMELEC ID VIN4620-0014B-|1479CAS20000

SUBCRIBED AND SWORN TO before me this 30th day of October 2019

in Dumaguete City, Philippines, affiant personally known to me to be the person
who executed and signed this affidavit.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.