REPUBLIC OF THE PHILIPPINES)

LAPU LAPU CITY) SS

AFFIDAVIT OF LOSS

I, JERVY V. NEMENZO, of legal age, single, residing at Seaside, Pusok, Lapu Lapu City,
Philippines, after being sworn in accordance with law, depose and say:

1. That I have been vaccinated with my first dose of the Sinopharm vaccine around last
September 18, 2021 and my second dose on October 18, 2021;

2. That due to the abovementioned Vaccination, I was duly issued a Vaccination Card;

3. However, the above-mentioned item was lost in my possession when the typhoon
Odette destroyed our area last December 16, 2021;

4. That despite diligent search and effort exerted to locate the said Vaccination Card, but
the same proved futile; hence, the same should now be considered lost;

5. I am executing the instant Affidavit to attest the veracity of the foregoing statements
and for the issuance of a new above-mentioned item Vaccination Card in lieu of the lost
one, and for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this March 17, 2022, in
Lapu Lapu City, Philippines.

JERVY V. NEMENZO
Affiant
ID No.: CRN-0006-2729126-3
Unified Multi-Purpose ID

SUBSCRIBED AND SWORN to before me this 17st day of March 2022 at Lapu-
Lapu City, Philippines, affiant personally known to me with his competent evidence of
identity abovementioned to be the same person who executed the foregoing affidavit
and avowed, and who signed this instrument in my presence, and avowed under the
penalty of law to the whole truth of its contents.

Doc. No. ____;

Page No. ____;
Book No. ___;
Series of 2022.