Republic of the Philippines )

City of Cabuyao)
Province of Laguna) S.S.

AFFIDAVIT OF LOSS

I, Royce Dimailig Villalobos, Filipino, of legal age, single and residing at Block 17 Lot
10 Hongkong Village Barangay Banay-Banay, Cabuyao City, Laguna, after having
been sworn to in accordance with law hereby depose and state:

That I am a holder of SSS Card bearing SSS Number CRN 0033-3478983-2 issued
by the Social Security System;

That I am a holder of Maxicare bearing No. 081200410-400 issued by Maxicare

Healthcare Corporation.

I lost the said ID cards while I was in the Emergency Room of Our Lady of Mary
Mediatrix Hospital in Lipa City, Batangas.

That the same could not be found despite diligent efforts to locate it;

That I am executing this affidavit to certify the loss of the above-mentioned ID for
the purpose of securing its replacement from the Social Security Systems and
Maxicare Healthcare Corporation.

AFFIANT FURTHER SAYETH NAUGHT.

______________________________
SIGNATURE OVER PRINTED NAME
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______________,

20___ in___________________ City, with affiant exhibiting his/her CTC No.
16508126, issued on August 11, 2014 at Cabuyao City, Laguna..

NOTARY PUBLIC
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20__