REPUBLIC OF THE PHILIPPINES )

City of Roxas ) S.S.

x-------------------------------------------x

AFFIDAVIT OF LOSS

I, RUFIL ODIO, Filipino, of legal age, single and a resident of

Brgy. Agcabugao, Cuartero, Capiz, after having been duly
sworn in accordance with law, hereby depose and state:

1. That I am a holder of a PRC I.D bearing I.D No.

1741789 issued by Professional Regulation
Commission;

2. That the said PRC I.D and its whereabouts could not
be ascertained;

3. That diligent effort to locate and search in places

where I have been on that day I lost it; however said
PRC I.D was nowhere to be found;

4. That said PRC Identification Card was not confiscated

by the authorities by any reason. Neither I violated
any rules and regulations;

5. That I am executing this affidavit to attest to the

truth of the foregoing facts and to request for a
replacement of said PRC I.D.

IN WITNESS WHEREOF, I have hereunto set my hand

this 23rd day of January, 2020 at the Roxas City, Philippines.

RUFIL F. ODIO
PhilHealth ID No. 11-
253334542-8

SUBSCRIBED AND SWORN to before me this 23rd day

of January, 2020 in the City of Roxas, Philippines. I further
CERTIFY that I have personally examined the affiant, and I
am fully satisfied that he voluntarily executed the foregoing
Affidavit, and he read and understood the contents thereof.