REPUBLIC OF THE PHILIPPINES }

CAGAYAN DE ORO CITY } S.S.

AFFIDAVIT OF LOSS

I, ________________________, of legal age, Filipino, single, and a resident of

____________________________________, after having been sworn to in accordance with law, hereby
depose and say that:

1. I am an owner of a Tenant ID Pass issued by ____________________;

2. Moreover, I am also an owner of a UMID ID;

3. I placed the said IDs together in a single ID sling;

4. However, sometime in January 2020, the said ID sling was lost while walking
at _________________;

5. Diligent efforts were exerted to find the IDs, but the same were irretrievably
lost;

6. I am executing this Affidavit of Loss to attest to the veracity of my statement

and for whatever purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this ________________ at

_____________________, Philippines.

___________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________________ in ____________________,

affiant exhibiting to me his PhilHealth ID with ID No. ___________________ issued by the
_____________ as competent proof of identification.

Doc No.  _____                                                             

Page No. ______                                           
Book No. ______                                              
Series of 2020.