AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) SS.

I, Nio J. Embalsado, Filipino, of legal age, single, and a resident of Buagsong, Cordova, Cebu, after
having been duly sworn in accordance with law, hereby depose and say:
1. That I am a holder of a company identification card bearing serial number CA0059 issued by
Philippines-AFRIMS Virology Research Unit (PAVRU);
2. That I used to put the said identification card in my pouch, among others;
3. That sometime on August 22, 2012, when I arrived home from work, I discovered that my
company ID card was no longer in my pouch where I used to place it;
4. Despite diligent search and efforts to locate said document, I could not find it.
5. That said company ID card was not confiscated by the authorities of Philippines-AFRIMS
Virology Research Unit (PAVRU) by reason of any violation of company rules and regulations;
6. That I am executing this affidavit to attest to the truth of the foregoing facts and to request for a
replacement of said company ID card from Philippines-AFRIMS Virology Research Unit (PAVRU)
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of ____________
20___ at _________________________, Philippines.

_________________________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO before me, a notary public in and for _____________________
this ____ day of ____________ 20___. The affiant, whom I identified through the following
competent evidence of identity: _______________, valid from ______________ to _____________
issued by ______________________________________ personally signed the foregoing instrument
before me and avowed under penalty of law to the whole truth of the contents of said instrument.
Notary Public
Doc. No. ..;
Page No. .;
Book No. .;
Series of 2012.