Republic of the Philippines )

Province of Northern Samar )S.S.

Municipality of Catarman )
x--------------------------------x

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, and a resident of

Brgy. 2 Poblacion, Catubig, Northern Samar, Philippines, after being duly
sworn to in accordance with law, hereby depose and state:

That I graduated Bachelor of Science in Criminology at the University

of Eastern Philippines-Catubig Campus, Catubig, Northern Samar. Thus, a
diploma was issued in my favour which was unfortunately lost or misplaced
by me;

That despite of diligent search and efforts to locate the said diploma, I
could not find such, that I now believe that it is lost beyond recovery;

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
diploma, in lieu of the one that was lost.

Affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this ______

at Catarman, Northern Samar, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________, in

Catarman, Northern Samar, Philippines, by affiant who is known to me to be
the same person who executed and personally signed the foregoing
instrument before me and avowed under penalty of law to the whole truth of
the contents of said instrument.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2023.