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REPUBLIC OF THE PHILIPPINES

CITY OF ROXAS. . . . . . . . . . . . . ..
X----------------------------------------X

AFFIDAVIT OF LOSS

I, _________________________________________________________, ___ ___years


of age, single/married, Filipino and a resident of _____________________________________,
after having been duly sworn to in accordance with law, hereby depose and say:

That I am a ______ year student taking:________________________________________


at Capiz State Univesity, Dayao Satellite College, Roxas City.

That the authorities of the above-mentioned school issued a School Identification Card in
my favor,

That the same was lost and that I exerted diligent efforts to locate the same, but no to
avail. Hence, it is now considered beyond recovery;

That I am executing this affidavit to attest to the veracity of the foregoing facts and in
order to request from the said school for the issuance of a new School Identification Card in my
favor in lieu of that which was lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________day of


_________________, 2017 at Roxas City.

____________________________________
Signature over printed name

RF NO. _____________________________
Issued at ____________________________
Issued on ____________________________
Contact Number_______________________

SUBSCRIBED AND SWORN to before me this ______________________________in


the City of Roxas, Capiz, Philippines.

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