REPUBLIC OF THE PHILIPPINES )

Province of Negros Oriental )

City of Dumaguete )S.S.
x - - - - - - - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, JENNIFER DIVINAGRACIA, of legal age, Filipino, married and currently

residing in Banilad, Dumaguete City, Philippines, after having been sworn in
accordance with law, hereby deposes and states the following :

1. That I am a registered Nurse of the Republic of the Philippines.

2. That being a registered nurse, I was issued a Professional Regulation

Commission (PRC) Identification card sometime in 1994.

3. That I have placed said PRC ID inside my wallet. However, sometime in

December 2018, my wallet which was in my bag got lost. I was in the
market then when I discovered that my wallet was no longer in my bag.

4. I tried to look for the said wallet, but to no avail. I suspect it was stolen from
my bag on my way to the market.

5. That despite diligent search and efforts to locate my wallet with my PRC ID,
I could not find the same such that I now believe that it is now lost beyond
recovery.

6. That the said PRC ID has not been confiscated by any government
agencies.

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

foregoing and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _________ at

Dumaguete City, Philippines.

JENNIFER DIVINAGRACIA
Affiant
UMID ID 0111-7047052-7

SUBCRIBED AND SWORN TO before me this ___________ in Dumaguete

City, Philippines, affiant personally known to me to be the person who executed
and signed this affidavit.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.