REPUBLIC OF THE PHILIPPINES )

City of San Fernando, Pampanga ) S.S.

AFFIDAVIT OF LOSS

I, SALVADOR A. RIVERA IV, of legal age, Filipino, and a

resident of #39 Unit R2 Phase 3 Villabarosa Dolores, City of San
Fernando, Pampanga, subscribing under oath, depose and state that —

1. I was issued an Identification Card by Jose B. Lingad

Memorial General Hospital with ID No. 2017-1104.

2. On June 06, 2020, I noticed that the said Identification

Card was missing;

3. Despite diligent search and efforts to locate the said

Identification Card, I could not find the same such that I now believe
that it is now lost beyond recovery; and

4. I am executing this Affidavit of Loss to attest to the truth

of the foregoing and to support the application for the issuance of new
one in lieu if the one which was lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this June 17, 2020 at City of San Fernando, Pampanga.

SALVADOR A. RIVERA IV
Affiant

SUBSCRIBED AND SWORN before me this June 17, 2020 at City

of San Fernando, Pampanga by affiant, personally known to me being
my co-employee, who is the same person who personally signed
before me the foregoing affidavit that he executed the same.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2020.