REPUBLIC OF THE PHILIPPINES)

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

AFFIDAVIT OF LOSS

I, HENRY U. APOSTOL, of legal age, Filipino citizen, with residence address at 1513
Guadalupe Bliss Phase 3, Cembo, 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 11 th day of October 2022, in

the City of Makati.

HENRY U. APOSTOL
Affiant

SUBSCRIBED AND SWORN to before me on this 11th day of October 2022, in the City
of Makati.

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SERIES OF: 2022.