Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT OF LOSS
I, _______________, Filipino, of legal age, single, and a resident
_______________, under oath do hereby depose and state, that:

I am a holder of an School Identification Card (School I.D.) duly issued by the

_______________;

It so happened, however, the said School I.D. was misplaced and is nowhere to
be found;

I declare under penalties of perjury that this affidavit has been made in good
faith verified by me and to the best knowledge and belief is true and correct;

Earnest efforts were exerted on my part to retrieve the same but to no avail;

This affidavit is being executed to attest to the veracity of the foregoing

instrument in order to establish the existence of the above-mentioned School I.D. and
the facts of its subsequent loss for purposes not contrary to law, morals, good custom
and public policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th day of May 2016 at
Cainta, Rizal.

_______________
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above
written, affiant exhibiting to me his Cainta Municipal Health Officer I.D. with Registration
number 15-12146 bearing his photo and signature as competent evidence of identity.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2016.