REPUBLIC OF THE PHILIPPINES)

PROVINCE OF NUEVA VIZCAYA)S.S.

MUNICIPALITY OF BAYOMBONG)

AFFIDAVIT OF LOSS

I, WINSEL JOHN A. LUNA, of legal age, Filipino, single, and a resident of Lamo, Dupax
del Norte , Nueva Vizcaya, having been duly sworn in accordance with law, hereby depose
and state that:

1. I am a bonafide holder of the following Identification Cards and Official Receipt and
Certificate of Registration, to wit:
a) Professional Driver’s License;
b) Official Receipt and Certificate of Registration issued by Land Transportation
Office (LTO) in Bayombong, Nueva Vizcaya;
c) Voter’s Identification Card issued by Office of the Election Officer in Dupax del
Norte, Nueva Vizcaya;
d) VISA Identification Card issued by the Dupax del Norte Police Station in Dupax
del Norte, Nueva Vizcaya;

2. All the above-mentioned Identification cards and Official Receipt and Certificate of
Registration were placed inside my wallet as well as my other important documents
and certain amount of money;

3. Sometime on August 8, 2013, I boarded a motorized tricycle near Saint Mary’s

University in Bayombong, Nueva Vizcaya and went to the residence of my
grandmother in San Nicolas, Bayombong, Nueva Vizcaya;

4. When I went back at my boarding house along CICM street in Bayombong, Nueva
Vizcaya in the evening of the same date, I noticed that my wallet, containing the
identification cards mentioned in paragraph 1 hereof, was already missing and despite
of diligent efforts exerted, I could longer locate, find or recover the said wallet including
the said identification cards and to the best of my knowledge, the same are truly lost;

5. The said identification cards has not been confiscated by any officer of the law or issuing
office or agency due to the violation of any law, statute, order, rule or regulation;

6. In the event that the lost identification cards should hereafter be found or located, I
undertake to forward or surrender the same to the issuing government agencies;

7. I am executing this affidavit to attest to the truth of the foregoing and hereby execute
this Affidavit for the purpose of securing replacements for the lost Personal
Identification Cards and Official receipt and Certificate of Registration issued by LTO.

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of February 2017
at Bayombong, Nueva Vizcaya.

WINSEL JOHN A. LUNA

Affiant
PhilHealth Identification Card No. 02-026520759-7

SUBSCRIBED AND SWORN to before me this 20th day of February 2017 at

Bayombong, Nueva Vizcaya.