Republic of the Philippines ) Form 1

Zamboanga City ) S.S.

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Affidavit of Loss


I, JUAN DELA CRUZ, Filipino, of legal age, residing at 7 Tumaga St., Zamboanga
City, after having been sworn in accordance with law hereby depose and state:

That I am the owner of an Ateneo de Zamboanga University school identification
card (ID) with a code number 070401 of the College of Law;

That sometime in May this year, while I was entering the school, I frisked my pocket
and found that my ID was not there; that it was not in my pocket to my surprise as I placed it
there before I left home for school ;

That I took the pain and diligence to look for the said ID, but to no avail; and

That I am executing this affidavit to attest to the truth of the foregoing and to request
from the Director of Student Affairs of Ateneo de Zamboanga University, a new ID in lieu of
the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 2
nd
day of August, 2012
in Zamboanga City, Philippines.

Juan dela Cruz
Affiant

SUBSCRIBED AND SWORN TO, BEFORE ME, this 2
nd
day of August, 2012 in
Zamboanga City, with affiant exhibiting his identity competently with Drivers license no.
29J0856, issued December 16, 2011 in Zamboanga City.


Atty. Alman-Najar Namla
Notary Public
Until December 31, 2013
RM 3, LDM Bldg
Pilar St., Zamboanga City
Attorneys Roll no. 74352
PTR 8623, 01/01/12; ZC
IBP 2358. 01/01/12; ZC
Doc. No. : 001
Page No. : 001
Book No. 001
Series of 2012