Republic of the Philippines )

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS

I, ________________, __ears old, Filipino citizen, single,

and a resident of _________________, Philippines, after having
been duly sworn to in accordance with law, do hereby depose and
state THAT:

1. As a student of the __________________, I was issued a

Student Identification Card (ID) with number
_____________;

2. On ___________, the said identification card was

misplaced/lost and could not be found/located;

3. All my diligent efforts exerted to find the said ID card

proved futile; hence, I now consider the same as lost and
beyond recovery;

4. My student identification card was never pledged or used to

secure any obligation;

5. I am executing this affidavit to attest to the truthfulness of

the above statements and to support my application for the
issuance of a new Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this

___ day of ______, 2018 at ___________.

_________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and

place indicated above. Affiant exhibited to me her ___________.

Doc. No.:________;
Page No.:________;
Book No.:________;
Series of 2018.