Republic of the Philippines ) Olongapo City________________ ) S.S. City/Municipality of_________ ) x- - - - - - - - - - - - - - - - - - - - - -x AFFIDAVIT OF LOSS OF SCHOOL I.D.

I, ______________________, of legal age, (single/widow/married to _____________________), (Complete Name) (Spouses Name if applicable) Filipino citizen and a resident of _______________, Philippines, after being sworn to in accordance with (City/Province) law, depose and state: That as a bonafide student of Lyceum of Subic Bay, Inc., I was issued a Student Identification Card (ID) No. _______________; (Student Number) That to my surprise, I discovered last _____________ that the said Identification Card could not (Date of Loss) be found; As all efforts to find the same proved unrewarding, it is now safe to conclude that recovery of the same is no longer possible; Thus, I execute this affidavit to establish its loss and to support my application for the issuance of a new Student Identification Card. IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ___________, (Day) (Month) 20____ at Barangay ___________, Olongapo City, Philippines. (Year) (Barangay)

________________________________ Signature over printed Name of Affiant

SUBSCRIBED AND SWORN TO before me, a notary public in and for _____________________ this ____ day of ____________ 20___. The affiant, whom I identified through the following competent evidence of identity: ________________ valid from ________ to ________ issued by Lyceum of Subic Bay, Inc. personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument.

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