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Republic of the Philippines

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City of Iloilo ) S.S.
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AFFIDAVIT OF LOSS

I, KEVIN C. RUBINOS, of legal age, Filipino, single and a resident of One
Lourdes, Fuentes St. Cor. Ledesma, Iloilo City, after having been duly sworn to in
accordance with law, do hereby depose:

That I was issued the following cards:

Card Issuing Authority
PRC ID Professional Regulations Commission
DRIVERS’ LICENSE Land Transportation Office
PHIL HEALTH ID PhilHealth

That the said cards were placed by me inside my wallet;

That on March 16, 2017, I found that such wallet was no longer in my
possession;

That diligent efforts to locate the said wallet were made by me but were
proven futile;

That the said wallet and all its contents are now deemed lost and beyond
recovery;

That I execute this affidavit to attest to the veracity of the foregoing
declaration, for the purpose of issuance of new cards in lieu of all that were lost
and for all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of March,
2017 at Iloilo City, Philippines.

KEVIN C. RUBINOS
Affiant

SUBSCRIBED AND SWORN to before me this 21st day of March, 2017, after
affiant exhibited to me his Social Security System I.D. with I.D. no. 09-3714258-1 as
competent proof of his identity.

Doc. No.: ____;
Page No.:____;
Book No.: ____;
Series of 2017.