Republic of the Philippines] C I T Y O F D A V A O ]ss.

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AFFIDAVIT OF LOSS I, ______________, single, Filipino and residing at ____________________, after having been sworn to in accordance with law do hereby depose and state THAT: (sample: PRC I.D.; statement of facts) a. I am a bona fide owner and holder of the Professional Regulation Commission identification (PRC I.D.) card numbered 732822. b. Sometime in April 2013, while staying at Cebu City, my wallet which contained the said PRC I.D. was stolen. c. The said wallet and its contents, including the said PRC I.D. can no longer be located and is now lost beyond recovery. d. I attest to the whole truth of the foregoing and I execute this Affidavit of Loss to secure a new PRC I.D. and for whatever legal purpose this may serve. IN WITNESS WHEREOF, I have hereunto affix my signature this 06 June 2013 at Davao City, Philippines.

_________________ Affiant

SUBSCRIBED AND SWORN TO before me this ______________, __________ presented her current and unexpired Philippine passport numbered EB0783891 valid until August 16, 2015 bearing her photograph and signature as competent proof of her identity.

Doc. No. ____ ; Page No. ___ ; Book No. ___ ; Series of 2013.