Republic of the Philippines Province of Cavite City of Trece Martires

) ) S.S. )

AFFIDAVIT OF LOSS
(Re: PhilHealth Identification) I, RITCHEL CERBO CASTILLO, of legal age, Filipino, and a resident of 612 Carapiohan, Santiago, Gen. Trias, Cavite, after having been sworn to in accordance with law, hereby depose and say: 1. That I am the authorized representative of BAYANI ARATAN QUIMSON a bonafide member of Philippine Health Insurance Corporation (PhilHealth) bearing the PIN: 081751093780; 2. Unfortunately, November 15, 2012, while at the vicinity of Chowking, Tagaytay BAYANI ARATAN QUIMSON notice that his PhilHealth Identification Card was no longer in his possession and he could only assume that the same inadvertently fell in the place without his knowledge; 3. That exerted earnest efforts to locate his PhilHealth Identification Card, but prove to no avail, hence it is now declared lost for all legal purpose; 4. I am executing this affidavit to attest of the foregoing facts under penalties of perjury; 5. I am further executing this affidavit to formally request the legal authorities of PhilHealth to issue a new PhilHealth Identification Card in lieu of the lost thereof and for whatever legal purpose it may serve.
IN WITNESS WHEREOF, I have hereto affixed my signature on this 22nd day of November 2012 at Trece
Martires City, Cavite.

RITCHEL CERBO CASTILLO Affiant SSS Id. No. : 33-4216157-8

SUBSCRIBED AND SWORN to before me this 22nd day of November 2012 at Trece

Martires City Cavite. Affiant exhibiting to me her competent proof of identity.

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164

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43

ATTY FE B AONUEVO
NOTARY PUBLIC - UNTIL DECEMBER 31,2012 ROLL OF ATTORNEY No. 35746, IBP No. 902501, 08-15-12 Imus Cavite PTR No: 1659307 01-02-12 TMC Cavite 4TH MCLE Exemption No. 000189
Unit 3, Provincial Capitol Site, Trece Martires City Cavite

Book : 55 Series of 2012