Republic of the Philippines)
Malolos, Bulacan ) S.S.
AFFIDAVIT OF LOSS
I, CATHERYN JAY C. MAGSUSI, of legal age, Filipino, and a resident of
Purok 2, Sta. Monica, Hagonoy, Bulacan, after having been duly sworn to in accordance
with law, hereby depose and say:
1.
That I am a bona fide member of the Philippine Health Insurance
Corporation with PhilHealth No. 21-025558818-9;
2.
That, as a member, I was issued a PHIC identification card bearing
the above-mentioned number;
3.
That, said identification card was lost/misplaced and despite due
diligent effort to locate the same prove futile and to no avail;
4.
That, said identification card was not confiscated from me by any
law enforcement agencies or the government;
5.
That said identification card was not utilized in any unlawful act/s;
6.
That to the best of my knowledge and information, said
identification card is now beyond recovery;
7.
That I am executing this affidavit to attest to the truth of the
foregoing facts and be used for whatever legal purpose it may serve.
IN WITNESS WHEREOF, I hereunto signed this __ day of August, 2022 at
_________, Bulacan.
CATHERYN JAY C. MAGSUSI
Affiant
ID No. _____________
SUBSCRIBED AND SWORN TO before me this __ day of August, 2022 at _________,
Bulacan.
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2022;