REPUBLIC OF THE PHILIPPINES )

City of _______________________ ) S.S

AFFIDAVIT OF LOSS

I, HARIKA AVESTRUZ, of legal age and residing at No. 160 Avenida Veteranoz, Tacloban City,

under oath, state:

1. That I was the Admin Officer of the PLGP: Introduction of Bridging Leadership and Hospital Scorecard

Orientation for Eastern Samar last September 30 to October 2, 2015.

2. That as to my knowledge, there were no scanned IDs for the Event.

3. That after Event, the Guest Folio, Hotel Certificate, Statement of Account, Actual list of room for all the

participants, and Official receipt for 50% Downpayment and Full payment were sent via LBC Courier

were misplaced and cannot be found until today, February 12, 2016.

4. That I am executing this Affidavit to attest to the truth of the foregoing facts and to use the same for

whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _____________ day of February

2016 at Tacloban City.

HARIKA AVESTRUZ
Affiant
SUBSCRIBE AND SWORN to before me this _______________________ at

__________________, Affiant exhibiting to me his PHILHEALTH No.

Doc No. _______

Page No. ________

Book No. ________

Series of 2016