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Republic of the Philippines) City of Cagayan de Oro ) S.S.

AFFIDAVIT OF LOSS
I, SHIAN T. TIGULO, Filipino, single, 2nd year college student of Ateneo de Cagayan, Xavier University and a resident of Villa Cristo Rey, Bonbon, this city after having been sworn to an oath in accordance with law, do hereby depose and say: 1. That I am a holder/owner of the Green Form duly issued by the Finance Unit of Xavier University sometime on April 2010; 2. That the abovementioned Green Form was in my possession until I discovered that the same thing is missing; 3. That diligent and earnest efforts to locate the same proved futile and said Green Form is beyond recovery; 4. That I am executing this affidavit for the withdrawal of my payment of Php 2,000.00 with the Finance Unit Xavier University on April 10, 2010 and for whatever legal purposes this may serve. IN WITNESS WHEREOF, I have hereunto affixed my signature this 12th day of May 2010 in Cagayan de Oro City, Philippines. SHIAN T. TIGULO Affiant

SUBSCRIBED AND SWORN to before me this in Cagayan de Oro City, Philippines.

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