REPUBLIC OF THE PHILIPPINES)

C I T Y O F M A K A T I ) S.S.

AFFIDAVIT OF LOSS

I, JERICO S. SOSMEÑA, of legal age, Filipino citizen, with residence address at 261- A
Blk. 7 West Rembo, Makati City, after having duly sworn to in accordance with the law do
hereby depose and state, that:

I am a holder and possessor of Yellow Card issued by Makati Health Plus;

I am executing this affidavit to attest to the truth of foregoing facts, for information
and guidance of proper authorities concern and for whatever legal purpose this affidavit
may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hand on this 02 nd day of May 2022, in the
City of Makati.

JERICO S. SOSMEÑA
Affiant

SUBSCRIBED AND SWORN to before me on this 02nd day of May 2022, in the City of
Makati.

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SERIES OF: 2022.