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Republic of the Philippines)

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AFFIDAVIT OF LOSS
I, ______________________________________________ of legal age,
Filipino and a resident of _____________________________________ under
oath state:
1. That I am a bonafide holder of the following identification /
PRC license / POSB ATM Card duly issued by the involved
office / bank / entity / commission as follows:
a. PRC License ID No. ________________ as a licensed /
registered nurse issued by the Philippine Regulation
Commission (PRC);
b. POSB ATM Card
c. Parkway Shenton PTE LTD Healthcard
2. That the said identification / PRC license / POSB ATM Card
were kept in my wallet together with my other identification
and pertinent documents;
3. That sometime on ___________________________ I found out
that my wallet (where the said identification / license / POSB
ATM Card were kept) got lost , believing it might have fallen
without my awareness or might have been misplaced
somewhere else during my travels;
4. That I exerted utmost effort to seek and recover the said
identification / PRC license / POSB ATM Card but it only
proved futile, as such it is now deemed lost beyond
recovery;
5. That I am executing this affidavit to attest to the truth of the
foregoing, to inform the concerned agencies / offices /
commission about the lost of my said identification / PRC
license / POSB ATM Card and for whatever legal purposes
this affidavit may serve best.
IN WITNESS WHEREOF, I hereunto affixed my signature this day
of ____________ at ___________________________________________.

_________________________________

Affiant
ID No: _____________________
Issued by: _________________

SUBSCRIBED AND SWORN to before me this __________ at


______________________________ by affiant who is personally known to me
and exhibited his competent identification as shown above.
)
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AFFIDAVIT OF LOSS
I, ADONIS JESS P. PAGDILAO, of legal age, single, Filipino and a resident of
Brgy. Loctugan, Roxas City, Capiz under oath state:

1. That I am the owner/holder of a PRC ID (Nursing) issued by the


Professional Regulation Commission (PRC) Office, Iloilo City;

2. That the said PRC ID was kept in my wallet together with my other
important and pertinent document;

3. That on September 29, 2012, when I looked for my said PRC ID, I
noticed that the same is nowhere to be found and could not be
located believing it might have fallen or misplaced somewhere else;
4. That I exerted utmost effort to seek and recover my said drivers
license but it only proved futile, as such that it is now deemed lost
beyond recovery;

5. That I am executing this affidavit to attest to the truth of the


foregoing, to inform the PRC Office about the lost of my said PRC
ID and to support my request for issuance of a new ID in lieu of the
one that is lost and for whatever legal purposes this affidavit may
serve best.

IN WITNESS WHEREOF, I hereunto affixed my signature at Roxas City, Capiz,


Philippines, this _______________.

ADONIS JESS P. PAGDILAO


Affiant
CTC/ID No. 29858655
Issued on: 4-23-12
Issued at: Roxas City

SUBSCRIBED AND SWORN to before me this ______________ at Roxas City,


Capiz, Philippines.