AFFIDAVIT OF LOSS

I, Franchezka Josephine Benito Carillo, Filipino, of legal age, and a resident of

Block 3 Lot 258 Phase 1C Kasiglahan Village San Jose Rodriguez Rizal, after
having been sworn to in accordance with law, do hereby depose and declare that I lost
the following document:

 Grade 12 Report Card

That diligent effort to locate the above stated document was undertaken, but still
not found.

That I executed this affidavit to attest to the truth of the foregoing facts for
whatever legal intent or purpose it may duly serve.

In witness whereof, I have hereunto set my hand this

________________________ at Rodriguez Rizal.

FRANCHEZKA JOSEPHINE B. CARILLO

Affiant

Subscribed and sworn to before me this ______________ at _______________,

affiant exhibiting to me his/her valid I.D._________________.

NOTARY PUBLIC
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