Republic of the Philippines)

C I T Y O F D A V A O ) SS.
x- - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS
I, MAR NIKKO SOMBILLA, Filipino, single, of legal age, and a resident
of B3L5 Awhag Village, Bacaca, Davao City, Philippines, after being duly sworn
to in accordance with law do hereby depose and say that:
1. I am a member of the Caritas Health Inc.;
2. By virtue of such membership, I was issued a health card;
3. Since I have already fully paid the said membership, I was instructed
to turn over the old card issued to me for me to be issued a new one;
4. However, the duly issued Caritas health card got inadvertently lost.
Notwithstanding diligent efforts exerted to find it, the same was not
found, recovered, or located, hence, considered lost and destroyed for all
intents and purposes;
5. I am executing this affidavit without any fraud or intent to deceive on
my part and I forever free any person from any liability that may arise
from this circumstance;
6. I am therefore executing this affidavit to attest to the truth of all the
foregoing and to apprise Caritas Health Inc. of such fact of loss and in
order for me to be given a new health card and for all other legal
purposes this affidavit may best serve.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 11 th
day of December 2015, at Davao City, Philippines.

MAR NIKKO SOMBILLA

Affiant
Drivers License ID No. L02-12-012802
SUBSCRIBED and SWORN to before me, in the City of Davao, this 11 th
day of December 2015, affiant exhibiting to me his competent evidence of identity
first written above below his name.

Doc. No. ______

Page No. _____
Book No. _____
Series of 2015.