REPUBLIC OF THE PHILIPPINES)

City of Manila
)s.s.

AFFIDAVIT OF LOSS
I, ROSE ANN CANOZA VARILLA, of legal age, Filipino citizen, with
postal address at No. 106 Maysan Road, Malinat, Valenzuela city, after having
been duly sworn to in accordance with law, do hereby depose and state,
that:
1.

I am a registered midwife with License No. 0143050;

2.

On 24 July 2015, after coming home from my duty at Solaire

Hotel and Casino, I noticed that my wallet was missing;

3.

My wallet contains all my personal identifications including

my Professional Identification Card;

4.

I religiously and patiently look for my missing wallet

containing my Professional Identification Card but much to my
effort I failed. The same is now considered lost and beyond
recovery;

5.

I am executing this affidavit to attest to the truth of the

foregoing statements, and in whatever legal purpose this affidavit
may serve;

6.

Further Affiant Sayeth Naught.

IN WITNESS WHEREOF, I have hereunto set my hand this 27 th day

of July 2015 at City of Manila, Philippines.

ROSE ANN CANOZA VARILLA

Affiant
SUBSCRIBED AND SWORN to before me this 27th day of July 2015
at Manila City, Philippines. Affiant ROSE ANN CANOZA VARILLA exhibited
to me her Passport No. EB9073418.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2015.

Notary Public