Republic of the Philippines )

_____________________ ) S.S.

AFFIDAVIT OF LOSS

I, MANNA ROSE CATALOGO TANALEON, Filipino, of legal age, married, and a

resident of Pag asa Bldg., Mabini St., Talisay City, Negros Occidental, after being duly
sworn to in accordance with law, hereby depose and state that:

1. Sometime in the of June 2018, when I was searching for my MEDICARD

HEALTH CARD under my mother’s name PERLITA C. TANALEON, I failed to
find the same despite diligent efforts to locate it.

2. I surmised that I inadvertently misplaced the aforementioned ATM Card in our

house or could have accidentally dropped the same somewhere.

3. The aforementioned MEDICARD HEALTH CARD could now be deemed

completely lost and beyond recovery by the reason of the above-cited
circumstance.

4. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing statement in order to secure a replacement of the same and for
whatever legal intents and purposes this may serve.

AFFIANT FURTHER SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ at ________________________, Philippines.

MANNA ROSE CATALOGO TANALEON

Affiant

SUBSCRIBED AND SWORN to before me, this __________________, by the

affiant whom I have identified through Competent Evidence of Identity when she exhibited
to me her Professional Identification Card No. 0075575 issued by the Professional
Regulation Commission which serves as her Competent Evidence of Identity pursuant
to the 2004 Rules on Notarial Practice.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.