Republic of the Philippines . . .

)
City of Cotabato . . . . . . . . . . .) S.s.

AFFIDAVIT of LOSS

I, ANGELICA M. LEYSA, of legal age, Filipino, single and residing at Broce Marquez
Compound Tamontaka Maguindanao, after having been sworn to oath in accordance with law,
hereby depose and state:

That I am a holder of the COLLLEGE DIPLOMA issued by Notre Dame University, Cotabato
City;

That sometime last week, when I arrived home from traveled, discovered that my College
Diploma was no longer in my safe keeping cabinet where I used to place it;

That despite diligent search and efforts to locate my college diploma, I could not find the
same as such, I now believe that it is lost beyond recovery;

This affidavit is executed to attest to the truth and veracity of the foregoing and to request
the replacement of the said driver’s license.

IN WITNESS WHEREOF, I have hereunto signed this document on 15 th day of March 2021 in
Cotabato City, Philippines.

ANGELICA M. LEYSA
Affiant
UMID No. CRN – 0113-0771040-3

ACKNOWLEDGEMENT

Before me, a Notary Public for Maguindanao and Cotabato City, appeared the party herein,
personally known to me as the same persons who executed this document and acknowledging to me
that the same was done according to their own will and need.

This document is consist of one (1) page including this page which this acknowledgement is
written is signed by me and sealed with my notarial seal on the day, place and date first above
written,

Doc. No. ;
Page No. ;
Book No. ;
Series of 2021.