REPUBLIC OF THE PHILIPPINES )

IN THE CITY OF I L O I L O )S.S.

X-------------------------------------------X

AFFIDAVIT OF LOSS

I, IRENE T. GUMBAN, of legal age, Filipino, single and with address at Zone II,
Tubungan, Iloilo, Philippines, after having been sworn to in accordance with law hereby depose
and state:

That I am the holder of school identification card issued by University of San Agustin ;

That the said school identification card was lost and misplaced last September 2018 when
I’m travelling a transportation jeepney from Tubungan to Iloilo City proper;

That I exerted serious efforts in trying to locate the said school identification card but I
was not able to find the same, hence, I deem it lost for all legal intents and purposes .

This affidavit is executed in good faith and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________________at Iloilo City, Philippines

IRENE T. GUMBAN
Affiant

SUBSCRIBED AND SWORN to before me this day of ___________________ at Iloilo

City, Philippines. Affiant exhibited to me her valid proof of identity.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2019.