Republic of the Philippines }

Province of Surigao del Sur } S.S

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

AFFIDAVIT OF LOSS

I, __________ , of legal age, single, Filipino, residing at (Please

fill in complete address) after being duly sworn to in accordance with
law, do hereby depose and say that:

1. I am the holder of Acknowledgement Receipt No.

__________ my application for Student Visa;

2. I have recently discovered that the said receipt may have been
lost or misplaced;

3. Despite all diligent efforts exerted to locate and recover the said
receipt, the same cannot be located and is now beyond recovery;

As such that I am executing this Affidavit of Loss to attest to the

truth of the foregoing facts and to support my application for the transfer
of interest in the Service Agreement Contract and for other legal purpose
that this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this 29th day of April, 2021, at Cantilan, Surigao del Sur.

__________________

Affiant

SUBSCRIBED AND SWORN TO before me, this ____ day of

_____ 2021, in the __________________, affiant exhibiting to me
her ________ as her Competent Evidence of Identity.

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