Republic of the Philippines )

Province of Pangasinan )
City of Dagupan ) S.S.

AFFIDAVIT OF LOSS
(Diploma)

I, (AFFIANT’S NAME), of legal age, Filipino, married to (NAME OF AFFIANT’S

SPOUSE, if any), and resident of (AFFIANT’S ADDRESS), after having been sworn in
accordance with law hereby deposes and states that:

1. I graduated from (NAME OF SCHOOL/COLLEGE/UNIVERSITY) on (DATE OF

GRADUATION) with a degree in (BACHELOR’S DEGREE) for which I was
subsequently issued by said (SCHOOL/COLLEGE/UNIVERSITY) on (DATE OF
ISSUE) a Diploma;

2. sometime on (DATE), I was looking for the said Diploma, but to my surprise, the
same could not be found (ADD, CHANGE OR MODIFY BY INSERTING THE
DETAILS NEEDED ACCORDING TO THE CIRCUMSTANCES);

3. despite earnest and painful efforts on my part to search, locate and retrieve the
aforesaid Diploma, the same proved me futile and in vain;

4. said Diploma was not confiscated by any officer of the law or the officers of (NAME
OF SCHOOL/COLLEGE/UNIVERSITY) by reason of any violation of any law,
ordinance, presidential decree or rules and regulations of said
(SCHOOL/COLLEGE/UNIVERSITY); neither was it offered as collateral for any
loan nor transferred to any person or entity nor used for any unlawful purpose; and

5. I am executing this affidavit to attest to the truth of the foregoing, to request from the
Registrar’s Office of (NAME OF SCHOOL/COLLEGE/UNIVERSITY) a
replacement copy of the said Diploma, and for all legal intents and purposes this may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day of

_______________, 20___ in the City of Dagupan, Province of Pangasinan, Philippines.

_________________________________
(AFFIANT’S NAME)
Affiant