REPUBLIC OF THE PHILIPPINES)

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

AFFIDAVIT OF LOSS

That I, CHARRY SALAZAR TUBALLA, of legal age, Filipino citizen, with residence
address at 409 Archer Street, Group 3, Post Proper Southside, Barangay Southside 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 of the
City Government of Makati;

I am executing this affidavit to attest to the truth of foregoing facts and to

inform the proper authorities concerned and for whatever legal purpose this affidavit may
serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto set my hand on this 06 th day of October 2022, in

the City of Makati.

CHARRY SALAZAR TUBALLA

Affiant

SUBSCRIBED AND SWORN to before me on this this 06 th day of October 2022, in the
City of Makati.

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SERIES OF: 2022