REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.

AFFIDAVIT OF LOSS

I, EUGENE E. AYON, of legal age, married, Filipino and currently

residing at Purok 1, Pavia, Iloilo, Philippines, after having been duly sworn to in
accordance with law hereby voluntarily depose and say:

1. That I am an employee and a holder of an identification card issued by the

Iloilo Mission Hospital, Iloilo City;

2. That I usually keep the said card in my bag;

3. That sometime in July 2022, while I was about to use the same ID Card, I
discovered that the above-mentioned ID Card was already missing and the
same could not be found;

4. That I looked for it in the places where it was possibly kept, but I could no
longer retrieve it despite diligent search;

5. That I consider the said ID Card, lost and beyond recovery;

6. That I execute this Affidavit of Loss to attest to the truth of the foregoing
facts and for whatever legal purpose it may best serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 21 st day of

August 2022 at the City of Iloilo, Philippines.

EUGENE E. AYON
Affiant

SUBSCRIBED AND SWORN to before me this 21 st day of August 2022,

at the City of Iloilo, Philippines. Affiant exhibited to me her PhilHeatlh ID with
no. 11-050034299-4, bearing his signature and photograph.

Doc. No.______;
Page No. _____;
Book No. ____;
Series of 2022.