REPUBLIC OF THE PHILIPPINES }

CAGAYAN DE ORO CITY } S.S.

AFFIDAVIT OF LOSS

I, ____________________, of legal age, Filipino, single, and a resident of _____________,

Cagayan de Oro City, after having been sworn to in accordance with law, hereby depose
and say that:

1. I am a graduate of Bachelor of Science in Psychology at Xavier University-

Ateneo de Cagayan in 2013;

2. As such, I was issued a diploma by the Registrar’s Office of Xavier University;

3. The said diploma was kept in the drawer of my room;

4. However, sometime in 2021, I noticed that the diploma was lost or

misplaced;

5. Diligent effort were exerted to find the said diploma, but the same cannot be
found;

6. Hence, I am executing this Affidavit of Loss to attest to the veracity of my

statements and for the issuance of my diploma from the Registrar’s Office.

IN WITNESS WHEREOF, I have hereunto affix my signature this 16 th day of

February 2022 at the City of Cagayan de Oro, Philippines.

_______________________________
Affiant

SUBSCRIBED AND SWORN to before me this 16th day of February 2022 in Cagayan
de Oro City, affiant is known to me as the same person who executed the foregoing
affidavit.

Doc No.  _____                                                             

Page No. ______                                           
Book No. ______                                              
Series of 2022.