Republic of the Philippines )

City of Mati, Davao Oriental) Ss

AFFIDAVIT OF LOSS
I, xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx, Filipino, of legal age, married, and a resident of
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx, under oath, state that:

1. I am the holder of a University of Southeastern Philippines (USEP) College Diploma;

2. Last December 4, 2012, during the onslaught of Typhoon Pablo, our residence in
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx was not spared and all our belongings were left in topsy-turvy;

3. After such incident, we were able to organize our belongings; however, my USEP
diploma could no longer be found despite diligent search. Thus, it is now considered lost and beyond
recovery;

4. In addition, yesterday, June 3, 2024, as I was looking for my driver’s license card, I could
not find it in my wallet;

5. Last week, I remembered seeing my toddler playing with my wallet but I was not paying
much attention to her at that time which made me believe that she could have taken the same and lost it;

6. I exerted diligent efforts to locate my driver’s license but to no avail and I therefore
considered the same as lost and beyond recovery;

7. I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this June 4, 2024 in the City of Mati, Davao
Oriental.

xxxxxxxxxxxxxxxxxxxxxxxxxxxx
Affiant
Nat’l ID No. xxxxxxxxxxxxxxxxxxxxxxxxxxx

SUBSCRIBED AND SWORN to before me this June 4, 2024 at the City of Mati, Davao Oriental, affiant,
personally appeared and exhibited to me his competent proof of identity as exhibited above.

Doc No. xx;

Page No. xx
Book No. xx;
Series of xx.