Republic of the Philippines }

Province of Surigao del Sur } S.S

Municipality of Cantilan
x------------------------------------x

AFFIDAVIT OF LOSS

I, ___________, of legal age, married, Filipino, residing at

Parang, Cantilan, Surigao del Sur after being duly sworn to in
accordance with law, do hereby depose and say that:

1. I am a graduate of Saint Michael College, Cantilan, Surigao del

Sur with a degree of Bachelor of Science and Commerce in 1982;

2. I was issued a diploma by the said school;

3. The said diploma was missing and must have been lost already
and despite all diligent efforts exerted to locate and recover, the
same cannot be located and is now beyond recovery;

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

foregoing facts and to support my request for a replacement
copy.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 15th day of April, 2021, at Cantilan, Surigao del Sur.

__________________

Affiant

SUBSCRIBED AND SWORN TO before me, this 15th day of

April 2021, in the Municipality of Cantilan, Surigao de Sur, affiant
exhibiting to me her _________ as her Competent Evidence of
Identity.

Doc No.
Page No.
Book No.
Series of 2021.