Republic of the Philippines )

City of Manila ) S.S.

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, of legal age, Filipino, single, and a resident of

________________________________________________ , after having been sworn in
accordance with law, hereby depose and state:

1. That I am the holder/owner/ or possessor of a Honorable Dismissal/ Transfer

Credentials dated 09 May 2014;
2. That I have recently discovered the said document is irretrievably lost and can no
longer be found despite diligent efforts to locate the same;
3. That the newly-issued Honorable Dismissal/Transfer Credentials shall be for the
use of La Consolacion College, Manila only.
4. That I executed this affidavit to attest to the truth of the foregoing and to support
a request for a replacement copy of the above-mentioned document;

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in the

City of Manila, Philippines.

Affiant

SUBSCRIBED and SWORN TO before me this _________________ in the City of

Manila, affiant having exhibited to me her driver’s license with no. ________, issued on
___________, at ________________________________.

Doc. No. :________

Page No. :________
Book No. I :______
Series of 20______