Republic of the Philippines

Balanga City, Bataan, Philippines

AFFIDAVIT OF LOSS

I, Wilson D. Lazarte, Filipino, of legal age, and a resident of West Calaguiman, Samal,
Bataan, after having been duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of university library card issued by the university librarian (Bataan
Peninsula State University) on May 2013;

2. That I used to put said library card inside my envelope;

3. That sometime on December 30, 2017, I discovered that my library card was no longer
in my said envelope where I used to place it;

4. I exerted all efforts to locate the same but I could not remember exactly where I
placed/left it and it is considered lost for all legal purposes;

5. The said library card was not confiscated by any officer of the law by reason of any
violation of any law, ordinance, presidential decree or rules and regulation of anything;
and neither was it offered as collateral of any loan;

6. That I am executing this affidavit to attest to the truth of the foregoing facts and to
request for a replacement of said library card from BPSU library.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th day of January 2018
at Balanga City, Bataan, Philippines.

__________________________________

Signature of Affiant over Printed Name

SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in
___________________ City, Bataan, Philippines.