Republic of the Philippines

City of Batangas ) S.S.

AFFIDAVIT OF LOSS
I, MELCHOR T. TULALIAN, married, of legal age, Filipino citizen and
with residence and postal address at Talumpok Kanluran, Batangas City,
after having been duly sworn to in accordance with law hereby deposes and
says that:
1 I am a bona fide member of Philippine Health Insurance
Corporation (PhilHealth) with Identification No. 09-200628580-7;
2 I made a payment for the month of October 2013 to December
2013 and January 2014 to March 2014 they issued to me an
Official Receipt for the said payment;
3 I kept the said Official Receipt inside my bag;
4 I have exerted diligent efforts to locate the same but to no avail,
the said official receipt appear to have been irretrievably lost;
5 I am executing this Affidavit of Loss to attest the truth of the
foregoing, to inform Philippine Health Insurance Corporation
(Philhealth) of the facts surrounding the loss and further for
whatever legal purpose this may serve.
FURTHER AFFIANT SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto set my hand this 4 th
of April at City of Batangas.

day

MELCHOR T. TULALIAN
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of April at City

of Batangas, affiant personally appeared MELCHOR T. TULALIAN with
Philhealth card with No. 09-200628580-7.

Doc. No: 122A;

Page No: 26;
Book No: VI;
Series of 2014.

/var/www/apps/conversion/tmp/scratch_5/342351703.docx