8/19/2019 Affidavit of Loss - ANGUSAN

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REPUBLIC OF THE PHILIPPINES…)

CITY OF MANDAUE…) S.S.

 AFFIDAVIT OF LOSS

I,XAVIER NN F. ANGUSAN, of legal age, Filipino, single and a resident of

Sta. Cruz, Guizo, Mandaue City after having been duly sworn to in accordance

 with law, hereby depose and state that:

1.I was issued a PhilHealth ID, SSS ID and Taxpayer’s Identification

Number ID;

2.Last January 14, 2016, my boarding house was targeted by robbers,

and in the course of the said robbery, my wallet, containing the

aforementioned IDs, was taken;

3.Despite earnest efforts to locate the whereabouts of the above-

mentioned cards, it could not be found and retrieved. As such, I believe that the said IDs are lost beyond recovery;

4.I am executing this affidavit to attest to the veracity of the foregoing

statements, and in compliance with the requirements for the issuance

of another PhilHealth ID, SSS ID and TIN ID, and for whatever legal

purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15

th

day of January 2016 at Mandaue City, Philippines

XAVIER NN F. ANGUSAN 

 Affiant

CTC No. 08580125

SUBSCRIBED AND SWORN TO before me this 15th day of January 2016

at Mandaue City, Philippines, affiant being personally known to me and

exhibiting his CTC No. as shown above.

Doc No. ________

Page No. _______

Book No._______

Series of 2016.