REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF BAGUIO )S.S.

AFFIDAVIT OF LOSS
I, MARICELINA C. LINGCAYO, Filipino, resident of #28 Upper P.
Burgos St., Baguio City, Philippines, on oath depose and say:

1. I am a holder of a Baguio General Hospital and Medical Center

Identification Card (BGHMC ID) with ID Number 1410019.

2. Recently I tried to look for the said BGHMC ID but the same could
not be found;

3. Despite diligent search and efforts to locate the said BGHMC ID, I
could not find the same such that I now believe it is now lost
beyond recovery;

4. The said BGHMC ID has not been surrendered to any person in

authority nor has it been confiscated by any government agency;

5. This affidavit is executed in order to lend credence to the facts

above stated and to support my intention of securing a new
BGHMC Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day

of April 2017 at Baguio City, Philippines.

MARICELINA C. LINGCAYO
Affiant
TIN No. 426-085-951

SUBSCRIBED AND SWORN to before me this __ day of April 2017

at Baguio City, Philippines, affiant exhibiting the above competent proofs of
identity:

Doc. No.______;
Page No.______;
Book No.______;
Series of 2017.