Republic of the Philippines)

Quezon City ) S.S

AFFIDAVIT OF LOSS

I, Vanessa Jennifer A. Demillo, of legal age, and a resident of San Mateo Rizal, after being sworn
in accordance with law, hereby depose and state:

1. That I lost my School Identification Card issued by the New Era University;

2. That sometime on November 22, 2017, I lost the said School Identification Card while I was
on my way to school.

3. That I exerted utmost effort to locate the said item but proved futile. Hence, I now consider it
lost and beyond recovery;

4. I have never sold/ pawned/ swapped/ exchanged/ given the aforesaid item in exchange for any
consideration, neither the same has been confiscated by authorities;

5. This affidavit is executed to make a formal report of the fact of loss of the aforesaid item and
request for the replacement of the same.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________________.

_______________________________
Affiant

SUBSCRIBED AND SWORN to before me in Quezon City this _______________ by

____________________, who has satisfactorily proven to me his identity through __________
with number ______________ issued at ___________ valid until ______________.

Doc. No. _____;

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