REPUBLIC OF THE PHILIPPINES)

City of Makati ) S.S.

AFFIDAVIT OF LOSS

I, NELIA R. GERONIMO, Filipino, of legal age, residing at 158-E, 18th

Street, East Rembo, Makati City, after having been sworn in accordance with law
hereby depose and state:

That my son CARLO R. GERONIMO have studied in Maximo

Estrella Elementary School in Makati City;

That his office issued a Report Card (Form 138) to him as he

graduated High School;

That sometime last week he endorsed the said card last 06

April 2011 after he arrived at school and I placed it in my bag.

That after receiving the said bag, I went to buy some stuff in
SM Makati;

That upon arriving at the house afterwards, I checked my

bag and can no longer find the said Report Card;

That I took pains to look for said Report Card, but to no avail;

That I am executing this affidavit to attest to the truth of the

foregoing and to request from Maximo Estrella Elementary School
copy of said Report Card.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

_______________. 20___ at _________________________.

NELIA R. GERONIMO
(Name Over Signature of
Affiant)

SUBSCRIBED AND SWORN to before me, this ____ day of ______________,

20___ in ___________________ City, with affiant exhibiting his CTC No. 22410063,
Issued on February 15, 2011 at Makati City.

NOTARY PUBLIC
Until December 31, 200___

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2011