REPUBLIC OF THE PHILIPPINES)

PROVINCE OF PANGASINAN ) S.S.

__________________ )
x- - - - - - - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS
That I, DEVIN B. ESPAÑOL, of legal age, Filipino Citizen, and a resident of Poblacion,
Burgos, Pangasinan. Philippines, after having been duly sworn to an oath in accordance
with law, do hereby depose and say:

That I am a holder the claiming stub for the renewal of my nurse license issued by
the PRC Binalonan;

That said CLAIMING STUB, was being kept/placed in my wallet for safekeeping, and
when I was to look for it, I noticed that the same was lost/missing;

That I have already exerted extra diligent efforts to find/locate the same but in vain
henceforth considered the same lost;

That the same was not been confiscated nor revoke by any authority for any
violations;

That I am executing this affidavit to attest to the truth of the foregoing facts and for
any legal intent it may best serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

_________________, Pangasinan.

DEVIN B. ESPAÑOL
AFFIANT
PDL: A09-98-010996

SUBSCRIBED AND SWORN to before me, this _________________ at _______________,

Pangasinan.

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Series of 2021