REPUBLIC OF THE PHILIPPINES )

Province of Leyte ) S.S.

Municipality of Villaba )
x-------------------------x

AFFIDAVIT OF LOSS
(OF FORM 137)

I, MIRAFLOR E. IMPOC, Filipino, of legal age, single and a resident of Sitio

Simboryo, Brgy. Fatima, Villaba, Leyte, Philippines, after being duly sworn to in accordance
with law, hereby depose and state that:

1. Sometime last month or on May 2017, I submitted my application for graduation to

the University Registrar of the Visayas State University (VSU) Villaba Campus;

2. Days after, I was apprised by the University Registrar of VSU-Villaba Campus that I
lacked the required Form 137 issued by Villaba Vocational High School;

3. I looked for the said Form 137 but to no avail. Said Form 137, together with my
other important documents, got lost because of Typhoon Yolanda that hit our
province sometime on November 2013;

4. That despite diligent search and efforts to locate the said Form 137, I could not find
it such that I now believe that it is now lost beyond recovery;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing,
to support my application for graduation with VSU-Villaba Campus and for whatever
legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day of June, 2017 at
Villaba, Leyte, Philippines.

_____________________
MIRAFLOR E. IMPOC
AFFIANT

SUBSCRIBED AND SWORN to before me, this 2nd day of June, 2017 at Villaba, Leyte,
by the Affiant who is personally known to me (or whom I have identified through competent
evidence of identity) and who exhibited her School Identification Card No. V15-01-0239 issued at
Villaba, Leyte, Philippines.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2017.