REPUBLIC OF THE PHILIPPINES)

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

AFFIDAVIT OF LOSS

I, RAMONA G. SARIEGO, of legal age, Filipino citizen, with residence address at

149-I 18th Avenue, East Rembo, Makati City, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and state:

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 16 th day of June 2022, in the
City of Makati.

RAMONA G. SARIEGO
Affiant

SUBSCRIBED AND SWORN to before me on this 16th day of June 2022, in the City of
Makati.

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SERIES OF: 2022.