Republic of the Philippines )

Pili, Camarines Sur ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, VAN HENRIECH SUMAYAO HUERNO, of legal age, Filipino, single, a residence of ZONE 5,
BINOBONG PILI CAMARINES SUR, after having been duly sworn to in accordance with law,
hereby depose and state that:

1. I am a holder of a Professional Regulation Commission identification card bearing

license number 1630422;
2. I used to put my identification card in my wallet;
3. sometime on August 30, 2019, when I arrived at home from work, I found out that my
wallet was missing;
4. despite diligent search and effort to locate the said wallet, I could not find it;
5. I execute this affidavit to attest to the truth of the foregoing.

Signed on the date and at the place indicated below.

Affiant
(Signature over Printed Name)
Competent Evidence of Identity

ID: PRC License

issued on: May 17, 2018
at: Legaspi City, Philippines
Registration no.: 1630422

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The
affiant exhibited to me his competent evidence of identity as indicated above.

Signed this ______________at ________________, ______________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No.
Page No.
Book No.
Series of