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Republic of the Philippines )

Province of Samar ))
City of Calbayog) s.s.

AFFIDAVIT OF LOSS
I, DAWNNY RUSS BAYSON TITOY, Filipino, of legal age, single, and a
resident of Barangay Cagbilwang, Oquendo District, Calbayog City, Philippines, after
having been duly sworn to in accordance with law, hereby depose and state: That--

1. I was a former student of Northwest Samar State University in Calbayog City;

2. I finished a degree in BS Criminology on March 30, 2016 and thereafter issued


a Diploma;

3. Only this month, I came to know that my diploma is missing for reasons I
cannot recall;

4. I came to know that the same has been lost, hence I have exerted diligent efforts
in locating the same, but to no avail;

5. I am executing this Affidavit to attest to the truth of the foregoing facts and to
justify my request for a copy or transcript of my Diploma and for whatever legal
purpose this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of


December 2017, at Calbayog City, Philippines.

DAWNNY RUSS BAYSON TITOY


Affiant
PRC ID: 0148406

SUBSCRIBED AND SWORN TO BEFORE ME, this ___ day of December


2017 in the City of Calbayog, Philippines, Affiant known to me and to me known to be the
same person who executed the foregoing instrument and acknowledged to me that the
same is their free and voluntary act and deed.

Doc. No. _____;


Page No. _____;
Book No. I
Series of 2017