Republic of the Philippines

City of Tacloban

AFFIDAVIT OF LOSS

I, ANGELINA A. VIVERO, of legal age, married, Filipino, and currently a

resident of Zone 1 Javier, Leyte, after having been duly sworn to in accordance
with law, hereby depose and say, THAT:

1. I am currently the school head of Manlilisid National High School,

Manlilisid, Javier, Leyte;

2. I am a participant of the REGIONAL ROLL-OUT FOR SCHOOL HEADS

DEVELOPMENT PROGRAM: FOUNDATION COURSE both in Module I
held on November 27 to December 3, 2017 as well as in Module 2
held on December 11 to 17, 2017 both programs held at Leyte Park
Hotel, Tacloban City;

3. As such I was issued by the Department of Education (DepEd) a

CERTIFICATE OF PARTICIPATION in both Module 1 and Module 2 of
said Course;

4. Recently, when I looked for the original copy of the CERTIFICATE OF

PARTICIPATION, the same could not be found and must have been
misplaced;

5. Despite of diligent search and efforts, the same could no longer be

found such that I now believe that it is now beyond recovery;

6. I am executing this sworn declaration to confirm the truth of the

foregoing statements and in support of my application with the
DepED for the issuance of a new CERTIFICATE OF PARTICIPATION
for the above-mentioned course.

IN WITNESS WHEREOF, I have hereunto set my hand this 25 th day of

September 2018 at the City of Tacloban, Philippines.

ANGELINA A. VIVERO
Affiant
PRC Reg No. 0260052

SUBSCRIBED and SWORN TO BEFORE ME this 25th day of September

2018 at Tacloban City, Philippines, affiant having personally shown to me her
identification card above-stated as proof of her identity.

Doc: 298 ATTY. SHARON R. VILLONES

Notary Public
Page: 61 N.C. No. 2017-07-68 until December 2018
Book: II IBP Lifetime No. 017319
Roll No. 67394/May 24, 2017
Series of 2018 PTR No. 7700050/January 8, 2018/Tacloban City
Kertz Apartment, Fatima Village
Brgy. 77 Marasbaras, Tacloban City 6500