REPUBLIC OF THE PHILIPPINES)

CITY
OF _______
)S.S.
X - - - - - - - - - - - - - - - - - - - - - - - -X

AFFIDAVIT OF LOSS
I, _____________________, Filipino, of legal age, single/married and a resident of
__________________________, Philippines, after having duly sworn to in accordance
with law, hereby depose and say that:
1. I am a holder of a student Identification Card issued by
_____________________________ ;
2. I lost said Identification Card on ____________________ and that I exerted all
efforts to locate the same but I could not remember exactly where I placed/left it
and it is considered lost for all legal purposes;
3. Said Identification Card was not confiscated by any officer of the law or the
officers of (name of school) by reason of any violation of any law, ordinance,
presidential decree or rules and regulation of said university; and neither was it
offered as collateral for any loan;
4. I am executing this affidavit to attest to the foregoing facts;
IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in
the City of _____________, Philippines.
________________
Affiant
SUBSCRIBED AND SWORN to before me this ____________ in the City of
__________, Philippines, affiant having exhibited to me his/her community tax
certificate with no. __________________ issued on _________________ at
______________ .

Doc. No. ________;

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