REPUBLIC OF THE PHILIPPINES)

ALFONSO, CAVITE ) S.S.

AFFIDAVIT OF LOSS

I, RYAN B. GALANG, Filipino, of legal age, single, with address at

Taywanak Ilaya, Alfonso, Cavite, after having been sworn to in accordance with
law, hereby depose and state, that:

1. On February 25, 2017 while I was on my way home, I accidentally dropped

my St. Francis Cabrini Medical Center Identification Card;

2. I declare said Identification card to be lost and cannot be recovered;

3. Despite diligent efforts to recover said identification card the same can no
longer be located;

4. I am executing this Affidavit for valid and legal purpose and not for any
unlawful purpose but for clearance purposes.

IN TRUTH WHEREOF, I have hereunto affixed my signature this 27th day

of February, 2017 at Alfonso, Cavite.

RYAN B. GALANG
Affiant

SUBSCRIBED AND SWORN to before me this 27th day of February, 2017,

Affiant exhibiting to me his _____________________.

WITNESS MY HAND AND SEAL.

Doc. No. 495;

Page No. 100;
Book No. XLVI;
Series of 2017.