Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, DERIC T. ALFORJA , of legal age, Filipino citizen, and resident of PNR Barangay
Poblacion Malvar, Batangas Philippines, after being duly sworn by law, hereby depose and
state under oath:

1. That I am the lawful owner/holder of the Form 137 from the School of Malvar Senior High
School located Brgy. Poblacion, Malvar, Batangas;

2. That the lost form 137 was lost and misplaced in our house, and I have exercised due care and
diligence to keep it safe and secure;

3. I have made a diligent search and inquiry to locate the lost Form 137 but to no avail. It is
irretrievably lost and cannot be found;

4. That the loss of the said Form 137 was not due to any negligence, willful act, or omission on
my part;

5. I am executing this Affidavit of Loss to attest to the truth of the foregoing facts and to apply
for the issuance of a copy of my Form 137.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st of May, 2024, in Malvar,
Batangas, Philippines.

DERIC T. ALFORJA
Affiant

SUBSCRIBED AND SWORN to before me this 21st day of May 2024, in Malvar, Batangas
Philippines, affiant exhibiting competent evidence of identity through TIN ID with ID number:
381-456-114, issued on 11/09/2020.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2024.