REPUBLIC OF THE PHILIPPINES

PROVINCE OF____________
CITY OF ______________

AFFIDAVIT OF LOSS

I, ________________of legal age, Filipino, married, and a resident of

_________________________, Philippines, after being duly sworn to in accordance with
law, hereby depose and state:

1. That I am a graduate of _____________________ in the School Year 1990-1991;

2. That sometime in December 2006, the strong typhoon Reming struck the province
of ________________;

3. That unfortunately after the typhoon our residence was ruined wherein, I kept my
High School Diploma;

4. That despite diligent search and efforts to locate the said Diploma I could not find
them such that I now believe that they are now lost beyond recovery

5. That I am executing this affidavit to attest to the foregoing facts and for purposes
of reissuance in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto affixed my signature ____________ day

of ______________________ at Sorsogon City.

__________________________________

SUBSCRIBED AND SWORN to before me this ___________ of _____________ at

Sorsogon City, affiant having exhibited her Identification card with no. written below her
name.

Doc. No. _______

Page No. ______
Book No. ______
Series of 2019.