REPUBLIC OF THE PHILIPPINES S.S.

QUEZON CITY

AFFIDAVIT OF LOSS

I, _______________________________--, of legal age, Filipino citizen, married,

with residence and postal address ____________________________---, Pasig City, after
being duly sworn to in accordance with law, hereby depose and state that:

a. I am a holder of an _______________- Student I.D., being a

sophomore college student of the College of _________ for
______________Course. My student I.D. No. is
_______________________;

b. Sometime in December 2019, while aboard an airplane for a local

trip to the south, I inadvertently left my purse which contains among
others, my ____________ Student I.D.;

c. Despite diligent effort exerted to locate the same, such effort proved
futile;

d. This affidavit is being executed to attest to the truth of the foregoing

facts and for the purpose of re-applying for a new
__________________----- Student I.D. and for whatever legal
intents and purposes this may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 17h day of

______________-, 2020 at Quezon City, Philippines.

______________________________--
AFFIANT

SUBSCRIBED AND SWORN to before me this 17th day of January, 2020 at

Quezon City, Philippines, affiant exhibiting her Philippines Passport numbered
______________.

Notary Public

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2020.