REPUBLIC OF THE PHILIPPINES)

CITY OF MANDAUE )S.S.

AFFIDAVIT OF LOSS

I, GRACE QUIROL BUGUINA, of legal age, Filipino, married, and a resident

Mantuyong, Mandaue City, after having been duly sworn to in accordance with law, hereby
depose and state that:

1. Last August 11, 2021, I took my first dose of Sinovac Vaccine at J Centre Mall
vaccination facility;

2. In view of such, I was issued a vaccination card bearing my identity as well as the
date and the vaccine shot I take;

3. The aforesaid Vaccination Card was usually placed inside the brown envelope
together with my all other documents;

4. I was scheduled to take my 2nd dose of vaccine this coming September 13, 2021 at the
same venue;

5. Unfortunately, last week while I was preparing the said Card, I found out that the
said Vaccination Card was no longer found inside the brown envelope ;

6. Immediately, I exerted diligent efforts to trace and locate the aforesaid Card but to
no avail. Hence, it is considered lost for all intents and purposes;

7. In the event that the said Vaccination Card should thereafter be found or recovered, I
undertake to forward or surrender the same to the authorities for its appropriate
disposal;

8. I execute this affidavit to attest to the veracity of the foregoing statements, and to
report the loss of the said item so I can be issued with a new Vaccination Card and
for whatever legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 20 th day of August

2021 at Mandaue City, Cebu, Philippines.

GRACE QUIROL BUGUINA

Voter’s ID No. 2230-0546B-D1892
Affiant

SUBSCRIBED AND SWORN TO before me this 20 th day of August 2021 at Mandaue

City, Cebu, Philippines, affiant sufficiently proved her identity by exhibiting to me her above
identification, as his competent evidence of identity under the 2004 RULES OF NOTARIAL
PRACTICE.

Doc No.____;
Page No.____;
Book No.____;
Series of 2021.