Date

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, (single / married), and a resident of

________________, after being duly sworn in accordance with law, depose and state:

That as a bona-fide student of______________________, I was issued a Student

Identification/Registration Card No._______;

That to my surprise, I discovered last ____that the said Registration Card could not be found;

As all efforts to find the same proved unrewarding, it is now safe to conclude that recovery of the
same is an impossibility;

Thus, I execute this affidavit to establish its loss and to support my application for the issuance
of a new Registration Card.

Affiant

(Signature over Printed Name)

Guardian

(Signature over Printed Name)