REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD
) Sc.
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AFFIDAVIT OF LOSS
I, GIAN KEVIN D. LADINES, of legal age, single, Filipino, and a
resident of PHHC, Blk. 6, lot 4, Bacolod City, after being sworn to in
accordance with law, hereby depose and say that:
1.

I previously have in my possession an

Identification Card as 3rd Year student of the
University of St. La Salle College of Medicine;

2.

On __________________________________, I
inadvertently lost the said identification which I
usually place inside my bag;

3.
Despite diligent efforts to recover my aforesaid I.D.
card, the same could no longer be recovered and as such, the
same must be deemed lost or destroyed for all legal intents and
purposes;
4.
I am now executing the foregoing affidavit in order
to attest to the truthfulness of the foregoing facts, to comply
with the requirements for the re-issuance by the University of St.
La Salle of the said Identification Card in lieu of the one which
was lost, and for whatever legal purposes this affidavit it may
serve.
IN WITNESS WHEREOF, I have hereunto
________________, in Bacolod City, Philippines.

set

my

hand

this

GIAN KEVIN D. LADINES

I.D. No. _________________________
SUBSCRIBED AND SWORN TO before me this _________________,
in the City of Bacolod, Philippines, Affiant appeared to me and shown her
Identification Card as noted above.
Witness my hand and seal.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2016