REPUBLIC OF THE PHILIPPINES )

CITY OF ) S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, single and a resident of , after having duly sworn to in accordance with law,
hereby depose and say that:

1. I am a holder of a Identification Card issued by Professional Regulation Commission;

2. I lost said Identification Card on and that I exerted all efforts to locate the same but I could not
remember exactly where I placed it and it is considered lost for all legal purposes;
3. Said Identification Card was not confiscated by any officer of the law by reason of any violation of
any law, ordinance, presidential decree or rules and regulation of the said Commission; and
neither was it offered as collateral for any loan;

I am executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this in the City of , Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _______________ in the City of __________, Philippines,
affiant having exhibited to me his/her community tax certificate with no. __________________ issued
on _________________ at ______________ .

Doc. No. ________;

Page No. ________;

Book No.________;

Series of 2011.