REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SURIGAO DEL SUR) s.s.

MUNICIPALITY OF TAGO)

AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

I, STEVEN U. BALANI, Filipino, of legal age, single, and a
resident of Purok Over The Rainbow, Bag-ong Lungsod, Tandag City,
Surigao del Sur, Philippines, after having been duly sworn to in
accordance with law, depose and state:
1.

That I am holder of an Identification Card issued by the

University of San Carlos, Talamban, Cebu City, being a
former student of the said institution;

2.

That said Identification Card was unfortunately lost and

its whereabouts cannot anymore be ascertained despite my
diligent search; and

3. That I am executing this Affidavit of Loss to attest to the

veracity of the foregoing and in support of my application for the
issuance of my Transcript of Records at the University of San Carlos,
Talamban, Cebu City.
IN WITNESS WHEREOF, I have hereunto affixed my signature
this 17th day of October, 2016 at Tago, Surigao del Sur, Philippines.

STEVEN U. BALANI
AFFIANT

SUBSCRIBED AND SWORN TO before me this 17 th day of

October, 2016 at Tago, Surigao del Sur, Philippines. The identity of
the affiant is established by his ID with No. 4142037.