REPUBLIC OF THE PHILIPPINES ) CITY OF CEBU ) S.c.

AFFIDAVIT OF LOSS I, Jonathan Yangyang, of legal age, single, Filipino and residing at ________________________, after being sworn to in accordance with law, depose and say that: 1. I was previously issued a Student Identification ard of the !niversity of ebu " #anilad a$pus% &. I used to 'eep the above($entioned Identification docu$ents in $y wallet% ard and other i$portant

). *ast +th day of ,ece$ber &-1), I left the said evidence of identity in .all, #anilad, ebu ity% /. find it% 0. 1he said evidence of identity is now beyond recovery% and

ountry

I tried all efforts to locate the $isplaced Identification ard but I was not able to

2. I a$ e3ecuting this sworn state$ent, as re4uired, to enable $e to obtain a replace$ent for that lost card. I5 6I157SS 68797:F, I have hereunto set $y hand this ___ day of __________, &-1/, in the ity of ebu, ;hilippines.

J:5<18<5 *. Y<5Y<5= Affiant JURAT S!#S 9I#7, and S6:95 to before $e, this ___ day of __________, in the ity of ebu co$plainant showing to $e his __________________ with I, 5u$ber __________ issued at __________________ on _________ as his co$petent evidence of identity.

,oc. 5o. ___% ;age 5o. ___% #oo' 5o. ___% Series of &-1/.
Page 1 of 1