Republic of the Philippines )

City of Tuguegarao )S.S.

AFFIDAVIT OF LOSS

I, _________________, of legal age, and a resident of

________________, Cagayan, under oath, hereby depose and say, that:

1. I am a graduate of _________________ at ___________ in the year

_____.

2. I was issued a Diploma, Certificate of Good Moral Character and

Form 137.

3. Said Diploma, Certificate of Good Moral Character and Form 137 was
missing and must have been lost sometime last year when Typhoon
Lawin struck the city. Despite long and diligent effort, it could no
longer be recovered.

4. I am executing this Affidavit to attest to the truth of the foregoing and

to support a request for replacement copy of the above-mentioned
documents.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________________ in __________________.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this _______________ in

_____________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2020.