Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT OF LOSS
I, ________________, Filipino, of legal age, single and a resident of
_______________, Philippines, after being sworn to in accordance with law
hereby depose and state:

1. That I am a board passer of the Licensure Examination for

_______________;

2. That as such, I was issued a Professional Identification Card with

issued by the Professional Regulation Commission (PRC for brevity);

3. That I usually placed the said Professional Identification Card

inside my wallet;

4. That sometime on _______________, I tried to look for the said

Professional Identification Card as intend to renew the same however I could
not find it in my wallet;

5. That despite diligent efforts and thorough search, the said

Professional Identification Card could no longer be found and might have been
misplaced without my notice, hence, I now considered the same as lost for all
legal intents and purposes; and

6.
7. That I execute this Affidavit to attest the truthfulness of the
foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my signature this

_______________ of _______________ in Tacloban City, Philippines.

_______________Affiant

SUBSCRIBED AND SWORN to before me this _______________ in

_______________ City, Philippines, affiant personally known to me to be the
same person who executed this Affidavit of Loss.

Doc. No.: ______;

Page No.: ______;
Book No.: ______;
Series of 2023.