REPUBLIC OF THE PHILIPPINE)

CITY OF GENERAL SANTOS) S.S.

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

AFFIDAVIT OF LOSS

I, ROSE MARIE T. TANDOY, Filipino, of legal age, married, and a

resident at Purok Tomasa Village, Calumpang. General Santos City, after having
been duly sworn to in accordance with law, do hereby depose and say:

1. That I am an employee of Saint Elizabeth Hospital Inc. office located

at National Highway, General Santos City;

2. That my employee identification card was lost sometime in December

2016. I searched for my identification card but I could not find it,
despite diligent efforts on my part to find it;

3. That I am executing this instrument in order to apprise the proper

authorities of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 11th day of

January 2017 at General Santos City.

ROSE MARIE T. TANDOY

Affiant

SUBSCRIBED AND SWORN to before me this 11 th day of January 201 in

General Santos City. Affiant identified by me through her Social Security
System#09-1193693-3, bearing her photograph and signature.

Doc No. 30;

Page No. 06;
DINNAH MAE A.
Book No. XII;
ALCONERA
Series of 2017. Notary Public, Until Dec. 31, 2018
Notarial Commission Serial No. P.N. C. No.16-42
Room 203/2F, Arenas Building,
Pioneer Avenue, General Santos City
Roll of Attorney No. 64187/ TIN No. 436-581-686
IBP Lifetime Member No. 015333, 04-05-16,
SOCGEN
PTR No. 7153518, 01-04-17, General Santos City
MCLE Compliance No. V-0017611, April 4, 2016