Republic of the Philippines)

City of ________________)

AFFIDAVIT OF LOSS

I, ABAQUITA, MARK JHON, Filipino, 15 years of age, with postal address at

Langtad City of Naga, Cebu, after having duly sworn in accordance with law hereby
depose and state:

1. That I am a bonafide student of Placido L. Señor National High School,

Langtad, City of Naga, Cebu.

2. That as such student, was issued a Filipino 9 book (Panitikang Asyano sa

Filipino) for SY 2015-2016.

3. That the said book was in my possession from the time of issuance but
sometime on January 20, 2016, Wednesday or thereabout, the same was lost
and notwithstanding diligent efforts, the same cannot be recovered or found.

4. That I am executing this affidavit to attest the truth and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________________ at

_________________________, Philippines.

ABAQUITA, MARK JHON

Affiant

SUBSCRIBED and sworn to before me in ______________, this day

____________of month 20___, affiant executing his/her Community Tax Certificate No.
___________, issued at _________ on _____________.

_______________________
Notary Public

Doc. No. _________

Page No.__________
Book No._________
Series of _________