REPUBLIC OF THE PHILIPPINES

CITY OF MUNTINLUPA

)S
) SS.

AFFIDAVIT OF LOSS
I, ______________________________________________, of legal age, Filipino,
with residence and postal address at _______________________________________
____________________________________, after having been duly sworn to in
accordance with law, do hereby depose and say, THAT:
1. I am a former student of _______________________________________ for the
academic year ________________ located at ____________________________
_____________________________and
such
Diploma/Transcript
of
Records/Form 138 Card/Form 137 Card was issued in my favor;
2. The said ___________________________________ was lost or misplace on
__________________________________________
in
the
vicinity
of
_________________________________;
3. I took diligent effort in retrieving those documents but the same were
proved to be futile, and the act of recovering the same is an
impossibility, and hence is to be considered as lost;
4. I execute this instrument in order to attest the truth of the above facts,
and for all the legal intents and purposes this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my
signature this _______ day of _________________ in the City of Muntinlupa.

_____________________________
Affiant
SUBSCRIBED AND SWORN to before me this _______________________ in
the City of Muntinlupa affiant exhibited to me his/her Competent Evidence of
Identity
No.
_____________________________
issued
by
_________________________________.
Doc. No.
_____ ;
Page No.
_____ ;
Book No.
_____ ;
Series of 2013.