REPUBLIC OF THE PHILIPPINES }

BACOLOD CITY, NEGROS OCCIDENTAL } S.S.

AFFIDAVIT OF LOSS

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

_________________________________, after having been duly sworn to in accordance
with law hereby depose and state that:

1. That I am a holder of a school library identification card issued by

__________________________________;
2. That I used to put the said library identification card in my pouch.
3. That sometime on _____________, when I arrived home from school,
I discovered that my library identification card was no longer in my
pouch where I used to place it;
4. Hereunder are the facts and circumstances surrounding the loss of my
Identification Card:
_________________________________________________________
_________________________________________________________
_________________________________________________________
5. That I made diligent search to recover the said Library Identification Card
but proved futile;
6. For all legal intents and purposes the said Library Identification Card
is now considered lost and beyond recovery;
7.

IN WITNESS THEREOF, I have hereunto set my hand this _____________ day

of ___________________20__, at __________________________, Philippines.

__________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________________ day of

______________________ 20__ , affiant exhibited to me his/her Driver’s License No.
__________________ issued at ___________________ on ______________________.

NOTARY PUBLIC

Doc. No. ___________;

Page No. ___________;
Book No. ___________;
Series of 20___