Republic of the Philippines)

Pasig City )S.S

AFFIDAVIT OF LOSS
I !!!!!!!!!!!!!!!!!!!!! of legal age an" #ith office a""$ess at
!!!!!!!!!!!!!!!!!!l un"e$ oath he$eby "epose an" say that%
&. That I a' a g$a"uate of Docto$ of (e"icine the )ni*e$sity of +ast Ra'on
(agsaysay (e"ical Cente$ (anila in &,,-.
.. That I #as issue" a Diplo'a by sai" )ni*e$sity.
/. That sai" Diplo'a #as 'issing an" 'ust ha*e been lost so'eti'es in (a$ch
.-&. #hen the$e #as a $eno*ation0e1tension of ou$ $esi"ential house. Despite long an"
"iligent it coul" no longe$ be $eco*e$e".

2. I a' e1ecuting this Affi"a*it to attest to the t$uth of the fo$egoing an" to suppo$t a
$e3uest fo$ $eplace'ent copy of the abo*e4'entione" Diplo'a.
AFFIA5T F)RT6+R SA7+T6 5A)86T.

I5 9IT5+SS 96+R+OF I ha*e he$eunto affi1e" 'y signatu$e this .2
th
"ay of
:uly .-&/
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Affiant
S);SCRI;+D A5D S9OR5 to befo$e 'e in Pasig City this .2
th
"ay of :uly
.-&/ by !!!!!!!!!!!!!!!!!!!! #ho has satisfacto$ily p$o*en to 'e he$ i"entity
th$ough !!!!!!!!!! #ith nu'be$ !!!!!!!!!!!!!! issue" at !!!!!!!!!!! *ali" until
!!!!!!!!!!!!!!.
Doc. 5o. !!!!!<
Page 5o. !!!!!<
;oo= 5o. !!!!!<
Se$ies of .-&/.