REPUBLIC OF THE PHILIPPINES)

City of Batangas) S.S.

AFFIDAVIT OF LOSS

I, HANNA SHARA CRUZAT DOMINGO, single, of legal age, Filipino and a

resident of Naujan, Oriental Mindoro, after being duly sworn to in accordance with law,
depose and state THAT:

1. I am an alumnus of San Pascual Senior High School of batch 2019;

2. Sometime in 2019, I received the original copy of my report card for school
year 2018-2019;
3. On July 2022, while preparing for enrollment for the upcoming school year, I
discovered that the said report card was missing;
4. Despite diligent efforts to locate it, the same could not be found and beyond
recovery;
5. As such, I am executing this Affidavit of Loss to attest to the truth of the
foregoing facts and serves as a compliance pertaining to my intention for the
academic requirement for my enrollment at Mindoro State University;

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

_______________________ at Batangas City, Philippines.

HANNA SHARA CRUZAT DOMINGO

Afffiant

SUBCRIBED AND SWORN TO before me this _____ day of ____________ at

Batangas City , affiant exhibiting to me her PhilHealth ID No. 09-251727197-9.

Doc. No. _____;

Page No. ____;
Book No. ____;
Series of 2022.