Republic of the Philippines)

Malolos City, Bulacan) S.S.

AFFIDAVIT OF LOSS
I, ______________________, of legal age, Filipino, and a resident of
______________________, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am the holder of student ID issued by the Polytechnic University of the

Philippines – Sta. Mesa, Manila with student number ______________________;

2. That sometime in February 2024, the said student ID got lost when I was travelling to
school;

3. That when I checked my ID case, the said student ID was lost;

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

5. That I am executing this affidavit to attest to the truth of the foregoing and to support
the application for the issuance of a new one in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________,
2024 here at the City of Malolos, Province of Bulacan.

______________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place above written.

Doc. No. ______

Page No. ______
Book No. ______
Series of 2024.