REPUBLIC OF THE PHILIPPINES)

CITY
OF ZAMBOANGA---------)S.S.
X - - - - - - - - - - - - - - - - - - - - - - - -X
AFFIDAVIT OF LOSS
I, _________________________________, Filipino, of legal age, single
and a resident of _________________________________________________
Philippines, after having duly sworn to in accordance with law, hereby depose
and say that:
1. I am a holder of a student Identification Card Number ____________
issued by _____________________________________________;
2. I lost the said Identification Card on _______________________ and that
I exerted all efforts to locate the same but I could not remember exactly
where I placed/left it and it is considered lost for all legal purposes;
3. Thus, I execute this affidavit to establish its loss and to support my
application for the issuance of a new Identification Card.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________
day of __________________ in the City of ____________________, Philippines.
_______________________________
Affiant

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 20____.