REPUBLIC OF THE PHILIPPINES)

DONE: IN THE CITY OF BAGUIO) S.S.

AFFIDAVIT OF LOSS

I, JONATHAN M. GARAPALAN, of legal age, Filipino citizen, single, residing

at Baguio City, after being duly sworn, hereby depose and say:

1. That I am a registered nurse by profession and currently employed on

contractual basis at the BAGUIO CITY GENERAL HOSPITAL AND
MEDICAL CENTER;

2. That on July 27, 2011 at about 2:00 o’ clock in the afternoon, a fire broke out at
the apartment where I was renting and gutted the entire building resulting to
massive loss of properties including my personal belongings. Attached hereto
and marked as Annex “A” is a machine copy of an excerpt of the police
blotter of the fire incident;

3. That among my personal properties and belongings that were burned were
my passport, PRC ID, PRC Certificate of passing, NC II certificate, IVT
Certificate, College Diploma, Transcript of Records, Red Cross Certificate,
Employment Certificate (SITEL-Baguio), SSS and PhilHealth Membership
Forms and ATM cards from BPI, BDO, and Metro Bank;

4. That I have already caused the replacement of the above-mentioned personal

properties and belongings, except my passport, NC II certificate, and my SSS
and PhilHealth Membership Forms;

5. That I am executing this affidavit for the purpose of applying and securing
another copy or replacement of my passport, NC II certificate, and my SSS
and PhilHealth Membership Forms and to attest to the truthfulness of the
foregoing.

JONATHAN M. GARAPALAN
Affiant

Subscribed and sworn to before me in Baguio City on the 22 nd day of September,

2011.