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Affidavit of Loss

Royce Dimailig Villalobos lost his SSS ID card and Maxicare healthcare card while in the emergency room of Our Lady of Mary Mediatrix Hospital in Lipa City, Batangas. He executed an affidavit to certify the loss of the cards and to request replacements from the Social Security System and Maxicare Healthcare Corporation. The affidavit details Royce's personal information, SSS number, and Maxicare number and states that despite diligent efforts, the cards could not be found after being lost in the hospital.

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1K views1 page

Affidavit of Loss

Royce Dimailig Villalobos lost his SSS ID card and Maxicare healthcare card while in the emergency room of Our Lady of Mary Mediatrix Hospital in Lipa City, Batangas. He executed an affidavit to certify the loss of the cards and to request replacements from the Social Security System and Maxicare Healthcare Corporation. The affidavit details Royce's personal information, SSS number, and Maxicare number and states that despite diligent efforts, the cards could not be found after being lost in the hospital.

Uploaded by

Beef Testosterone
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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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__

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