Republic of the Philippines)

City of Ormoc ) S.S.

AFFIDAVIT OF LOSS

I, LENY S. BILBAO, of legal age, Filipino and a resident of Albuera,

Leyte, Philippines after having been duly sworn to in accordance with law
hereby depose and state, THAT:

1. That I was issued and in possession of Certificate of Full Payment

issued by Caritas Health Shield;

2. That said document was lost due to inadvertence and without fault on
my part and the same was not seized or confiscated from me;

3. That since its loss, I have been exerting diligent efforts in locating the
same to no avail, thus said document was considered lost for all intent
and purposes;

4. That I execute this affidavit to attest to the truth and veracity of the
foregoing facts and for whatever purposes this affidavit may serve
best.

IN WITNESS WHEREOF, I have hereunto set my hands this _ day

of _____________, 2020 in Ormoc City, Leyte, Philippines.

LENY S. BILBAO
Affiant
PRC: 0068998

SUBSCRIBED AND SWORN to before me this _ day of

_____________, 2020 in Ormoc City, Leyte, Philippines.

Doc. No. _______

Page No._______
Book No.______
Series of 2020