REPUBLIC OF THE PHILIPPINES

CITY OF LAS PIAS

)
) SS.

AFFIDAVIT OF LOSS
I, AGATHA DOMINIQUE BACANI, Filipino, of legal age, and a resident of Block 3
Lot 3 Molave St., Admiral Village, Talon III, Las Pias City, Metro Manila, after having been
duly sworn in accordance with law, hereby depose and say:
1.
That I am a holder of a school identification card bearing student number 0662014-0012 issued by STI COLLEGE LAS PIAS;
2.
That sometime on October 14, 2015 , when I arrived home from school, I
discovered that my school ID card was no longer with me;
3.
Despite diligent efforts exerted, I could no longer locate, find or recover the said
school identification card, and to the best of my knowledge, the same is truly lost
4.
The said school identification card has not been confiscated by any officer of the
law or the issuing office or agency due to the violation of any law, statute, order, rule or
regulation.
5.
I am executing this Affidavit to attest to the truth of the foregoing statements and
to request the issuance of a new school identification card in lieu of the one which was lost.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____day of
____________ 2015 at ____________, Philippines.

AGATHA DOMINIQUE O. BACANI

Affiant
SUBSCRIBED AND SWORN TO before me, a notary public in and for
_____________________ this ____ day of ____________ 2015. The affiant, whom I identified
through the following competent evidence of identity: _____________, valid from______
to______ issued by_______________, personally signed the foregoing instrument before me and
avowed under penalty of law to the whole truth of the contents of said instrument.

Notary Public

Doc. No. _____

Page No. _____
Book No. _____
Series of 2015