Republic of the Philippines)

Municipality of Baao SS

AFFIDAVIT OF LOSS OF ELEMENTARY SCHOOL DIPLOMA

I, LENIE BOLO TRIUMFANTE, single/married, of legal age, Filipino,

residing at Zone 2, Sagrada, Baao, Camarines Sur, after being duly sworn to
in accordance with law, do hereby depose and say that:

1. I finished my elementary education at the SAGRADA ELEMENTARY

SCHOOL and graduated thereat in 1968;

2. As such, I was issued an elementary diploma by the said school;

3. Last April 28, 2023, I discovered the loss of the said elementary
school diploma from among my belongings.

4. Efforts were exerted to locate and recover the said elementary school
diploma, but in spite of diligent search, the same cannot be located
and is now beyond recovery;

5. In the event that the said elementary school diploma should hereafter
be found or recovered, I undertake to forward or surrender the same
to the said school, for its appropriate disposal;

6. I am executing this Affidavit to attest to the truth of the foregoing and

to support a request for my SSS Pension.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 5th

day of May 2023, at Sagrada Elementary School, Sagrada, Baao, Camarines
Sur, Philippines.

Lenie Bolo Triumfante

Affiant

SUBSCRIBED AND SWORN TO before me this __________________ in

Cebu __________________________________, affiant exhibiting to me his
competent evidence of identity by way of: (_______________________).

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of _____.