REPUBLIC OF THE PHILIPPINES

Province of ___________________
Municipality of ________________
BARANGAY __________________

Date

AFFIDAVIT OF LOSS

I, ____________________, Filipino, of legal age, single, and a resident of

____________________________________Philippines, after being duly sworn in accordance
with law, hereby depose and state that;

1. That I am the owner, holder of the ______________ and _________________ issued by

_____________________ during my Graduation Last ____________________
2. That the said documents/ School Records were kept on the file cabinet in my room.
3. That I recently discovered that said documents/school records are irretrievably lost and
can no longer be found despite diligent efforts to locate the same;
4. I execute this affidavit to attest to the truth of the foregoing.

Signed on 19th day of June at the _________________________,

_____________________________

________________________
Affiant
ID No.__________________
Issued on._______________
At_____________________

Certified and verified this ___________________. At Office of the

___________________________.

_______________
Punong Barangay