Republic of the Philippines)

City of Cebu………………..)S.S.

AFFIDAVIT OF LOSS

I, ALYSSA YZABEL C. TAN, of legal age, with address at 792 F. Pacana

St. Tisa, Cebu City, after having been sworn to in accordance to law, hereby
depose and say:

1. I am currently a Grade 11 student enrolled at Cebu Doctor’s University. A copy

of my study load is herein attached as Annex “A”;

2. As such, I was duly issued a Student Identification Card (ID) with ID NO.
21727196;

3. Sometime on July 10, 2017, said Student ID was misplaced and got lost;

4. Efforts were exerted to locate said Student ID, but in spite of diligent search, it
could not be found and the same is now beyond recovery;

5. Said Student ID has not been confiscated by Cebu Doctor’s University for any
violation or for any purpose whatsoever;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing
and to support my application for the issuance of a new Student ID, in lieu of the
one that was lost;

IN WITNESS WHEREOF, I have here unto set my hands this ______ day of
______________, 2017 in Cebu City, Philippines.

ALYSSA YZABEL C. TAN

Affiant

With my conformity and consent:

MARY ELIZABETH C. TAN

Mother of Affiant

SUBSCRIBED AND SWORN TO before me, this ____ day of _________,

2017 at Cebu City, Philippines. Affiant showing to me her Identification Card
mentioned below her name as proof of her identity, appeared and signed the
foregoing instrument in my presence within my jurisdiction, and who avowed to
the truth of its contents under penalty of law.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2017.