Republic of the Philippines)

CITY OF DAVAO . . . . . ..) S.S.

X----------------X

AFFIDAVIT OF LOSS

I, AAA, of legal age, Filipino and a resident of Davao City, Philippines, after
having been duly sworn to in accordance with law do hereby depose and state:

That I am a holder of a Vaccination Card issued by the City Government

of Davao;

That the above-mentioned Vaccination Card issued by the City

Government of Davao has been inadvertently lost from my possession and despite of
diligent efforts to locate it, the same could no longer be found;

That I am executing this affidavit to attest the truth of the foregoing facts for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signatures this 19 TH day of

July 2023 at Davao City, Philippines.

AAA
Affiant
POSTAL ID PRN 111111

SUBSCRIBED AND SWORN TO before me 19TH day OF July 2023 at Davao City,
Philippines.

Doc. No. ________;

Page No. ________;
Book No. _______;
Series of 2023.