REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) SS.

AFFIDAVIT OF LOSS

I, EVELYN CONTURNO LARENA, Filipino, of legal age, and a resident of Blk. 77 L51,
P3 Marycris Complex PASCAM2 Gen. Trias, Cavite, after having been duly sworn in
accordance with law, hereby depose and say:

1. That I am the owner/possessor of Veterans Memorial Medical Center (VMMC) issued

Temporary Medical ID;

2. That sometime in June 2018, the above mentioned item was inadvertently lost or might have
been misplaced due to unknown circumstances;

3. That despite diligent efforts exerted to locate the same, all efforts proved fruitless up to the
present, I have not located the same, and fear that the same was already lost beyond recovery;

4. That I am executing this affidavit to attest to the truth of the foregoing instrument and for any
legal purposes and intent this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 12th day of

December 2018 at Quezon City, Philippines.

EVELYN CONTURNO LARENA

Affiant
ID NO. OTAG0074170
Issued on 20/11/2018
Issued by AFP, OTAG

SUBSCRIBED AND SWORN TO before me on this 12th day of December 2018, in Quezon
City. Affiant exhibited to me his/her identification documents as indicated above as proof of herein
affiant’s identity.

Doc No.______
Page No._____ NOTARY PUBLIC
Book No._____
Series of 2018.