REPUBLIC OF THE PHILIPPINES )

Province of Leyte ) S.S.

Municipality of Villaba )
x-------------------------x

AFFIDAVIT OF LOSS

I, NELSIE LAPORE, Filipino, of legal age, single and a resident of Brgy. Cagnocot,
Villaba, Leyte, Philippines, after being duly sworn to in accordance with law, hereby depose and
state that:

1. On February 28, 2017, I submitted my application for graduation to the University

Registrar of the Visayas State University (VSU) Villaba Campus;

2. On April 3, 2017, I was apprised by the University Registrar of VSU-Villaba Campus

that I lacked Form 138, a required piece of document for graduation;

3. On the same day, I looked for my Form 138 but to no avail. Said Form 138, together
with my other important documents, got lost because of Typhoon Yolanda that hit our
province sometime on November 2013;

4. That despite diligent search and efforts to locate the said Form 138, I could not find it
such that I now believe that it is now lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing,
to support my application for graduation with VSU-Villaba Campus and for whatever
legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day of April, 2017 at
Villaba, Leyte, Philippines.

____________________
NELSIE LAPORE
AFFIANT

SUBSCRIBED AND SWORN to before me, this 10th day of April, 2017, by the Affiant
who is personally known to me (or whom I have identified through competent evidence of identity)
and who exhibited her School Identification Card No. V13-01-0079 issued at Villaba, Leyte,
Philippines.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2017.