(Affidavit of Loss - School ID)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)

x-----------------------x

AFFIDAVIT OF LOSS

I, _____________, Filipino, of legal age, (single / married), and a resident of _____________,

after being duly sworn in accordance with law, depose and state:

1 That as a bona-fide student of _____________, I was issued a Student Identification Card

(ID) No. _____________;

2 That to my surprise, I discovered last _____________ that the said Identification Card could
not be found;

3 As all efforts to find the same proved unrewarding, it is now safe to conclude that recovery
of the same is an impossibility;

4 Thus, I execute this affidavit to establish its loss and to support my application for the
issuance of a new Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,

Philippines.

AFFIANT
(JURAT)