REPUBLIC OF THE PHILIPPINES )

CITY OF KABANKALAN ) S. S.
x ------------------------------------- x
AFFIDAVIT OF LOSS
(School ID)

I,_________________________________________, ____ years of age, single/married,

Filipino and a resident of ______________________________________,after having been duly
sworn to in accordance with law, hereby depose and say:

That I am a _____ year student taking ________________________________________

at __________________________________________, Kabankalan City;

That the authorities of the above-mentioned school issued a

___________________________________________ in my favor;

That the same was lost and that I exerted diligent efforts to locate the same, but to no
avail. Hence, it is now considered beyond recovery;

That I am executing this affidavit to attest to the veracity of the foregoing facts and in
order to request from said school for the issuance of a
new_________________________________________ in my favor in lieu of that which was lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of

___________________, 2014, at Kabankalan City, Negros Occidental, Philippines.

____________________________________
Signature over printed name
CTC NO.
_____________________________
Issued at ________________________
Issued on _______________________
Contact No. ______________________

SUBSCRIBED AND SWORN to before me this _____ day of _______________

2014, Kabankalan City, Negros Occidental, Philippines. Affiant exhibited to me his/her
Community Tax Certificate as above-stated and his/her
______________________________________, as proof of Identity. I hereby certify that I have
personally examined the affiant, and I am satisfied that he/she voluntarily executed and
understood the allegations stated in his/her affidavit.

JOY R. INFANTE-GUILOT
PUBLIC ATTORNEY II
Roll No. 52815
IBP No. 929495/3-11-14/Bacolod City
PURSUANT TO PAO LAW (RA 9406)