Republic of the Philippines

(X__________________X) S. S.

AFFIDAVIT OF LOSS

I, JOHN JOSEL CEDRICK D. CARMONA, single, Filipino and a resident of

___________________________, after having been duly sworn to in accordance with law hereby
depose and say:

1. That I am a student of Grade 9 Section St. Justin de Jacobis with student no. 20160227
of Adamson University.

2. That I am the owner of a report card for SY 2018-2019 issued by Adamson University.

3. That on June 26, 2019, I discovered that the said report card was lost and despite diligent
efforts to locate its whereabouts, it is nowhere to be found and is now considered loss and
beyond recovery.

4. I am executing this affidavit for whatever legal purpose it may serve and to request for a
replacement of said report card.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of June 2019 at City of
Manila.

JOHN JOSEL CEDRICK D. CARMONA

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ____ day of June 2019 at City of Manila,
affiant personally appeared with his competent evidence of identity.

Doc. No. _____

Page No. _____ NOTARY PUBLIC
Book No. _____
Series of 2019