REPUBLIC OF THE PHILIPPINES)

_____________________________ ) SS.

AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

I, LOVELY L. DE LA TORRE, Filipino, of legal age, and a resident of Ungka II,

Pavia, Iloilo, accordance with law, hereby depose and say:

1. That I am a holder of an identification card bearing serial number 12345

issued by the Professional Regulation Commission (PRC);

2. That I used to put said identification card in my wallet;

3. That sometime on March 25, 2018, when I arrived home from a drinking
spree and night clubbing with friends, I discovered that my PRC ID card was
no longer in my wallet where I used to place it;

4. Despite diligent search and efforts to locate said identification card, I could
not find it.

5. That said PRC ID card was not confiscated by the authorities of the
commission by reason of any violation of rules and regulations;

6. That I am executing this affidavit to attest to the truth of the foregoing facts
and to request for a replacement of said ID card from Professional Regulation
Commission.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 27th day of

March 2018 at Iloilo City, Philippines.

LOVELY L. DE LA TORRE
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO before me, a notary public in and for Iloilo City
this 27th day of March 2018. The affiant, whom I identified through the
following competent evidence of identity: Driver’s License No. 12345, valid from
April 11, 2017 to April 11, 2022 issued by the Land Transportation Office,
personally signed the foregoing instrument before me and avowed under
penalty of law to the whole truth of the contents of said instrument.

ATTY. LOVELY L. DE LA TORRE

Notary Public for and in the City and Province of Iloilo
My Commission No. is 28
Expires on December 31, 2019
De La Torre Law Office, 8th Floor,
Excelsior Bldg., Iloilo City
Roll of Attorneys No. 19283
PTR NO. 2651863, 05/17/17, Iloilo City
IBP NO. 2122, 05/17/17, Iloilo City
Doc. No. 4;
Page No. 2;
Book No. 1;
Series of 2017;