REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

MUNICIPALITY OF DARAGA )

AFFIDAVIT OF LOSS

I, Shaira Mae M. Cuevillas, of legal age, Filipino, single, and resident of Phase #1
Velasco St. Doa Maria Subdivison, Daraga Albay, Philippines, after being duly sworn
according to law, hereby depose and state that:
1. I am the registered owner of Registered Medical Technologist Identification Card
No. 0072644 issued by the Professional Regulatory Commission on May 21, 2016 at Morayta
St., Manila, Philippines.
2. Sometime in February 2017, when I was commuting home, I discovered that the
PRC ID was no longer in my wallet.
3. Despite diligent efforts exerted, I could no longer locate, find or recover the said
identification card, and to the best of my knowledge, the same is truly lost.
4. The said Identification Card has not been confiscated by any officer of the law or
the issuing office or agency due to the violation of any law, statute, order, rule or regulation.
5. In the event that the lost Identification Card should hereafter be found or located,
I undertake to forward or surrender the same to the Professional Regulatory Commission for
appropriate disposal.
6. I am executing this Affidavit to attest to the truth of the foregoing statements and
to request the issuance of a new PRC Identification Card in lieu of the one which was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of May 2017 at
Daraga, Albay, Philippines.

SHAIRA MAE M. CUEVILLAS

Affiant
SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to
me
his/her Competent Evidence of Identity by way of __________________ issued at
______________ on
__________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.