REPUBLIC OF THE PHILIPPINES)

QUEZON CITY, METRO MANILA) S.S.

AFFIDAVIT OF LOSS
I, DR. NAPOLEON PALITAN BORJE, of legal age and resident of B8 L1 & 2
Happy Homes 2, Sarmiento Village, Brgy. Tandang Sora, Quezon City, after
having sworn, do hereby voluntarily state that:

Around March 2010 I moved out of my old clinic at 6/F Liberty Building,
835 Arnaiz Avenue., Makati City 1226 and opened a small clinic in my
above-mentioned residence in Quezon City;

Recently, as I was sifting through all my records, I noticed that certain

documents and other important items were missing.

Some of these important documents and items include the following:

Official
Official
Official
Official
Official
Official

After diligent search conducted in my clinic and the rest of my house, I

concluded that the said missing documents were most probably lost in
transit while I was moving out of my old Makati clinic;

I am executing this statement to attest to the truth of the foregoing

and to substantiate whatever other legal purpose it may serve.

Receipts
Receipts
Receipts
Receipts
Receipts
Receipts

Pad
Pad
Pad
Pad
Pad
Pad

No.
No.
No.
No.
No.
No.

7, 301 350;
8, 351- 400;
3, 101 150;
23, 1101 -1150;
28 1351 -1400; and
1401 1450;

IN WITNESS WHEREOF, I have hereunder affixed my signature this

12.28.11 in Quezon City.

DR. NAPOLEON
PALITAN BORJE
SUBSCRIBED AND SWORN to before me a Notary Public of Quezon City
this 12.28.11 with Affiant showing to me his PRC ID No. 40431, issued in
Manila.

Doc. No. 67
Page No. 07
Book No. 01
Series of 2011.

ATTY. IAN RAYMOND A. PANGALANGA

Notarial Commission until 12.31.12
Roll No. 37308, LT IBP 007730
PTR No. 9419454/QC/09392828084
Libra Cor. Capricorn Sts, Carmel 5 Subd., Tandang Sora,
Quezon City