REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO--------------------) S.S

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

AFFIDAVIT OF LOSS
I, NORIELLE O. INOSANTO, of legal age, single, Filipino and a resident of 182 Osmena St.,
Arevalo, Iloilo City, Philippines, after having been duly sworn accordance with law, hereby depose and
say:

1. That I am a holder of Covid - 19 Vaccination Card issued by Iloilo City RHU with the
dates of 1st Dose, on June 25, 2021 and 2nd Dose on July 23, 2021 with Sinovac as the
Vaccine Manufacturer;

2. That after the said Vaccination Card was issued in my favor, I kept it in our house,
together with my other papers;

3. That thereafter, I tried to locate the same, but it can no longer be found, despite diligent
efforts exerted;

4. That henceforth, I consider said Covid - 19 Vaccination Card issued to me as already lost
and beyond recovery;

5. That I am executing this affidavit to affirm the truth of the foregoing and to comply the
requirements for the issuance of the replacement of my Covid - 19 Vaccination Card and
for whatever legal purpose it may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of July 2021 at
Iloilo City, Philippines.

NORIELLE O. INOSANTO
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of July 2021 at Iloilo City ,Philippines,
Affiant Norielle O. Inosanto exhibiting to me her Driver’s License I.D No.____________ Issued by the
Land Transportation Office

Notary Public
Doc No ______ ;
Page No.______;
Book No.______;
Series of 2021