REPUBLIC OF THE PHILIPPINES)

S.C.
CITY OF MANILA )

AFFIDAVIT OF LOSS

I, _______________, of legal age, single, Filipino, with residence and

postal address at _______________________, after being sworn to in
accordance with law, do hereby depose and state that:

1. I am a fourth year B.S. Office Administration student, enrolled at

the _______________, for the second semester, 2018-2019 school
year;

2. I was issued an Identification Card (ID) with number: 000000 for

the said school year;

3. I usually put said ID in my bag, when I am not in school;

4. On _______________ at around 5:30 in the afternoon, upon arriving

home from school, I noticed that my ID was not inside my bags;

5. I made diligent efforts to locate said ID but was fruitless. Hence,

the same is now beyond recovery;

6. I am executing this affidavit to establish its loss and to support my

request for replacement of the said ID from ______________.

FURTHER, affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________ day of __________ 2019 in the City of Manila, Philippines.

___________________
Affiant
 SUBSCRIBED AND SWORN to before me this __________day of
__________ 2020, affiant exhibiting to me her residence certificate with
number ____________________ issued on ____________________ in
_____________.

NOTARY PUBLIC

Doc No. _____

Page No. _____
Book No. _____
Series of _____