REPUBLIC OF THE PHILIPPINES )

PAOAY, ILOCOS NORTE ) S.S.

AFFIDAVIT OF LOSS

I, DARVIN LEE RAYMUNDO MATEO, Filipino, of legal age, and a

resident at Brgy. #8 San Agustin, Paoay, Ilocos Norte, Philippines, having
duly sworn to in accordance with law, hereby depose and say that:

1. I am a holder of a nurse Identification Card issued by Professional

Regulation Commission;

2. I lost said Identification Card on last year 2020 and that I exerted all
efforts to locate the same but I could not remember exactly where I
placed it and it is considered lost for all legal purposes;

3. Said Identification Card was not confiscated by any officer of the law
by reason of any violation of any law, ordinance, presidential decree or
rules and regulation of the said Commission; and neither was it
offered as collateral for any loan;

4. I am executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this _______

at Paoay, Ilocos Norte, Philippines.

DARVIN LEE RAYMUNDO MATEO

Affiant

SUBSCRIBED AND SWORN to before me this _______________ at

Paoay, Ilocos Norte, Philippines, affiant having exhibited to me his/her
Driver’s License No. A03-10-002462.

Doc. No. ________;

Page No. ________;
Book No.________;
Series of 2011.