Republic of the Philippines

)
Province of Negros Occidental )
City of Bacolod
)
x---------------x

AFFIDAVIT OF LOSS
I, Ma. Karina B. De Leon, Filipino, of legal age, single, and a resident of Bantayan Road, Villa
Angela Subd., Bacolod City, Negros Occidental, Philippines, after duly sworn to in accordance
with law, hereby deposes and states:
That I am a medical student of University of St. La Salle, Bacolod City, Negros
Occidental;
That on December 5, 2015 at around 2:00 pm more or less, while on my way to our
house, I noticed that I no longer have in my possession my School I.D. which I usually placed it
in my bag;
That despite diligent search and effort to locate said school I.D., I could not find it such
that I now believe that it is lost beyond recovery;
As such, I am executing this affidavit to attest to the veracity of the foregoing and to
support my application for the issuance of a new school I.D. in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day of
January 2016 at Bacolod City, Negros Occidental, Philippines.

MA. KARINA B. DE LEON

Affiant

SUBSCRIBED AND SWORN to before me this 15th day of January 2016 at Bacolod
City, Philippines. Affiant exhibit to me her Tax Identification No. 460-167-618, issued at
Bacolod City, Negros Occidental, Philippines.

Atty. JOSEPH GEDEONI C. VALENCIA

Notary Public
Until December 31, 2016
Roll No. 46640
IBP O.R. No. 1008455/1-6-2016
PTR O.R. No. 0344689/1-5-2016
Bacolod City

Doc. No. 273

Page No. 55
Book No. III
Series of 2016