REPUBLIC OF THE PHILIPPINES )

CITY OF CEBU ) S.S.

AFFIDAVIT OF LOSS

I, ---------------, of legal age, Filipino, single and a resident of -----------------------, after having
been duly sworn to in accordance with law, hereby depose and state:

1. That I am a holder of a ----------- card bearing serial number --------------- issued by

------------------;

2. Sometime in ---------------, said ------------ was misplaced and got lost;

3. Efforts were exerted to locate said Student Identification Card, but in spite of diligent search, it
could not be found and it is considered lost for all legal purposes;

4. Said Identification Card was not confiscated by any office of the law by reason of any
violation of any law, ordinance, presidential decree or rules and regulation of the said School;

IN WITNESS WHEREOF, I have hereunto set my hand this ----------- in Cebu

City, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity
by way of __________________ issued at ______________ on __________________.

Doc. No. _____;

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