REPUBLIC OF THE PHILIPPINES )

____________________________) SS.
AFFIDAVIT OF LOSS

I, SHIELA MAE P. BAYO-ANG, Filipino, of legal age, single, and a resident of Makati
City, after having been duly sworn in accordance with law, hereby depose and say:
1. That I am a holder of HEALTH CARD which was duly issued to me by the
Pasig City Health Office;
2. Unfortunately, while I am organizing all of my things after I arrived at my place
of residence on June 16, 2016, I discovered the said card was missing or
could no longer be found. I must have dropped it while I was riding a public
utility vehicle during my travel;
3. Despite diligent efforts on my part to locate the same, it could no longer be
located; and
4. That I am executing this affidavit to attest to the truthfulness or veracity of the
foregoing facts and a request for a replacement of the same as well as for
whatever legal purposes this may serve.
Affiant Further Sayeth Naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 16th day of June
2016 at Pasig City, Philippines.

SHIELA MAE P. BAYO-ANG

Affiant
SUBSCRIBED AND SWORN to before me this ____ day of ______ in _________,
Philippines, affiant exhibiting to me his/her competent evidence of identity by way of TIN
ID No. ________________ issued at ___________ on ________________.
Doc No. : _____;
Page No.: ______;
Book No.: ______;
Series of _______.

Notary Public