Republic of the Philippines )

__________________________ ) S.S.

AFFIDAVIT OF LOSS

I, REGGIE MAGDARAOG RAÑOLA, of legal age, Filipino, single, and a

resident of Bucal, Brgy. Sampaloc II, Dasmariñas City, Cavite, after being duly sworn
to in accordance with law, hereby depose and state that:

1. I graduated from Tarlac Annex National High School located in Tarlac,

Tarlac on March 2006 and subsequently thereafter, DECS Form 138 Card
has been issued in my favor by the aforementioned academic institution.

2. That I have been in possession of the said Form 138 until such time that
our house has been demolished in a publicly conducted forced demolition
sometime on March 2010.

3. Despite diligent efforts to locate the above-described Form 138 Card, I

failed to locate the same as it is likely to have been included in the things
belonging to us that were permanently lost during the forced demolition
that was conducted.

4. I firmly believed that the said Form 138 is now completely lost and beyond
recovery in view of the circumstance cited above.

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing statement, to secure a replacement of said Form 138 Card and
for whatever legal intents and purposes this may serve.

AFFIANT FURTHER SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand this

________________________ at _______________________________.

REGGIE M. RAÑOLA
Affiant

SUBSCRIBED AND SWORN to before me, this __________________________, by the

affiant whom I have identified through a Competent Evidence of Identity which is his
SSS No. 33-2571036-9.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.