REPUBLIC OF THE 

PHILIPPINES)
Province of _____________ ) S.S.
Municipality of _____________ )
x------------------------------------------x
  
AFFIDAVIT OF LOSS
(RE: PRC ID)

I, ______________________, of legal age, Filipino, single/married/widow,

and a resident of _____________________________________, after having been duly
sworn to in accordance with law, depose and state THAT:

1. As a registered nurse, I was issued a Professional Regulation Commission

(PRC) Identification Card;

2. The said PRC ID has been in my possession and I placed it in my wallet for
safekeeping;

3. However, three months ago on August 10, 2022, I have noticed that my PRC
ID was no longer inside my wallet and I probably have misplaced the same;

4. For the past three months, I tried to find and locate said PRC ID but despite
diligent search and efforts, I could not find it such that I now declare it lost
beyond recovery;

5. I tried to ask my household member if they have seen it but all answered in
the negative;

6. I am executing this affidavit to attest to the veracity of my statements in

support of my request for the issuance of a new PRC ID, in lieu of the one
that was lost, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this _________________ at ______________________, Philippines.

________________________
Affiant
ID No. ______________________
Issued on: ___________________

SUBCRIBED AND SWORN TO before me

this _________________________ in Javier, Leyte, Philippines, affiant exhibiting to
me her competent evidence of identity as indicated below her name.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.