Republic of the Philippines)

City of Pasig ) S.S.

AFFIDAVIT OF LOSS

I, , of legal age, Filipino Citizen, with residence and postal address at, after
having duly sworn to in accordance with law do hereby depose and state:

That I am a holder and in possession of a HIGH SCHOOL DIPLOMA issued

in the name of, being a High School graduate therein, Batch 2010;

That recently last January 15, 2021, while looking for the aforesaid in my
envelop where it is kept, I found out that the envelop and the DIPLOMA inside it,
was already missing, probably was included in the thrown out to the garbage and
was burn, during the general cleaning conducted in our house;

That I exerted all efforts to locate or find the said HIGH SCHOOL DIPLOMA,
but proved futile and meaningless, whatsoever.

That I am executing this AFFIDAVIT to attest to the truth and veracity of the
above statements for all LEGAL INTENTS and PURPOSES it may serve best.

IN WITNESS HEREOF, I have hereunto signed my name this 10 th day of

February 2021 at Pasig City, Metro Manila.

-
Affiant

SUBSCRIBED & SWORN to before me in the City of Pasig, this 10 th day of

February 2021, by -, who has satisfactorily proven to me her identity through her
PASSPORT ID No. -, issued by DFA Manila that she is the same person who
personally signed before me the foregoing affidavit and acknowledged that she
executed the same.

Doc. No. ____

Page No.____ NOTARY PUBLIC
Book No. ____
Series of 2021