Republic of the Philippines )

MUNICIPALITY OF SANTO TOMAS ) S.S.

Province of Davao del Norte )
x-------------------------------------------x

AFFIDAVIT OF LOSS
I, MARIO P. AGUSILA, of legal age, Filipino, single and a resident of Purok 6, Brgy.
Bobongon, Sto. Tomas, Davao del Norte, Philippines, after having been sworn to in
accordance with law, do hereby depose and state that:

1. I am the same affiant who personally and voluntarily caused the preparation and
execution of this affidavit;

2. I am the biological father of John Harold P. Agusila, who was born on June 10,
2006 at Davao City, Davao del Sur, Philippines to my common-law spouse,
Dolores O. Padernal;

3. My aforementioned minor-aged son is a bona fide student of Davao Winchester

Colleges, Inc. – Feeder Road #4, Brgy. Tibal-og, Sto. Tomas, Davao del Norte,
Philippines, of which he had been issued a school identification card;

4. Sometime on the 14th day of October, 2019, he discovered that his school
identification card was missing from his back pack. He believed that the same was
fallen unnoticed somewhere within the vicinity of Brgy. Tibal-og, Sto. Tomas,
Davao del Norte, Philippines;

5. The whereabouts of his said school identification card cannot be ascertained

despite due and diligent search. Thus, I deemed it to be permanently lost;

6. The said school identification card was neither sold, assigned nor transferred or
any interest thereof of the funds represented thereby to any person, natural or
juridical, in any manner whatsoever;

7. This affidavit is executed as proof of such loss;

8. I am further executing this affidavit to attest to the veracity of the foregoing

declarations, to apprise the concerned authorities and for whatever legal purpose
it may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this October 15, 2019
at Sto. Tomas, Davao del Norte, Philippines.

MARIO P. AGUSILA
Affiant

SUBSCRIBED AND SWORN to before me this October 15, 2019 at Sto. Tomas,
Davao del Norte, Philippines.

Doc. No. 285;

Page No. 57;
Book No. 240;
Series of 2019.