Republic of the Philippines)

City of Davao )S.S.

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

AFFIDAVIT OF LOSS

I, THERESA R. SAMSON of legal age, Filipino, single, and a

resident of Brgy. Communal, Buhangin, Davao City, after having been duly
sworn in accordance with law, hereby depose and say that:

1. I am the person whose personal circumstances are described in

this affidavit;

2. Sometime second week of August 2019 while I was claiming my

remittance money at M Lhullier Clavera branch office Davao City, I
inadvertently left my Professional Regulation Commission
Identification document (PRC I.D.) in said branch as I hurriedly
left the premises due to some pressing concerns. When I returned
to said branch office, my PRC I.D. could no longer be found.

3. I exerted due diligence and persistent efforts in locating said PRC

I.D. but to no avail and I now consider the same as irretrievably
lost.

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

all the foregoing and to use the same for whatever legal purpose it
may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

18 day of September 2019 at Davao City, Philippines.
th

THERESA R. SAMSON
Affiant

SUBSCRIBED AND SWORN to before me this 18th day of September

2019 at Davao City, Philippines. Affiant, for purposes of identity, exhibited
to me her __________________.

Doc No. ___;

Page No. ___;
Book No. ___;
Series of 2019.