REPUBLIC OF THE PHILIPPINES) Province of Pampanga ) S.S.

City of Angeles ) x------------------------x AFFIDAVIT OF LOSS I, ANGELIQUE LACAMIENTO Y GALLARDO, Filipino, of legal age, single, and a resident of Barangay Sapangbato, Angeles City, after being duly sworn in accordance with law, depose and state: 1 That as a bona-fide employee of Nanox Philippines, Inc., I was issued an employee Identification Card (ID Card); 2 That to my surprise, I discovered last 30 November 2013 that the said Identification Card could not be found; 3 As all efforts to find the same proved unrewarding, it is now safe to conclude that recovery of the same is an impossibility; 4 Thus, I execute this affidavit to establish its loss and to support my application for the issuance of a new Identification Card. IN WITNESS WHEREOF, I have hereunto set my hand this 5 November 2013 at Angeles City, Philippines.

ANGELIQUE G. LACAMIENTO Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is personally known to me (or whom I have identified through competent evidence of identity) and who exhibited his/her Community Tax Certificate No. _____________ issued at _____________ on _____________.

NOTARY PUBLIC Doc. No. ______; Page No. ______; Book No.______; Series of 2013.