Republic of the Philippines))

Municipality of Silang, Cavite)) s.s.

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

AFFIDAVIT OF LOSS

I, HEBER JOY L. CORRO, Filipino citizen, of legal age, presently residing at Bungad
Biluso, Silang, Cavite after having been duly sworn to in accordance with the law, do hereby
depose and say:

1. Sometime last year, I received two (2) doses of CoVid-19 vaccination

administered by the Rural Health Unit of the Municipality of Silang;
2. I obtained vaccination card issued by the abovementioned RHU as proof of
vaccination that I present to establishments and used to travel to work, and
daily essential errands.
3. That sometime last week, I found out that the said card had been missing and
I could not locate it;
4. That I exerted diligent effort in locating the said lost vaccination card, but to
no avail;
5. That I hereby declare that the said vaccination is lost and beyond recovery;
6. That I am executing this affidavit to attest to the veracity of the foregoing
facts to report the missing vaccination card and request a new one from
Silang RHU.

IN WITNESS WHEREOF, I hereby affix my signature this __________ day of _____________

in the year _____________ in ___________________________________.

HEBER JOY L. CORRO

Affiant

SUBSCRIBED AND SWORN to before me this ________ day of ________________ in the

year _________ affiant having exhibited to me her _________________________ with number
__________________________ issued in_____________________________ on __________________________________
and valid until _______________________________ at _____________________________________.

Doc. No.: _______________________

Page No.: _______________________
Book No.: _______________________
Series of: _______________________