AFFIDAVIT OF LOSS

I, ___________, of legal Age, Filipino, single, with a residential address at Brgy. Sta. Cruz,
Villa Arevalo, Iloilo City, subscribing under oath, hereby depose and state:

1. That I am the holder of a TRAINING RECORD BOOK issued by the SHIPMENT TRAINING
OFFICE of JOHN B. LACSON FOUNDATION MARITIME UNIVERSITY located in Sto. Nio Sur,
Villa Arevalo, Iloilo City;

2. That on June 5, 2017, I was looking for the said TRAINING RECORD BOOK but to my
surprise, said document could not found;

3. That the TRAINING RECORD BOOK could not be found notwithstanding diligent efforts to
locate the same and is now considered lost for all legal intents and purposes;

4. That I certify this oath to report the loss of the TRAINING RECORD BOOK issued by the
SHIPMENT TRAINING OFFICE to avoid the said missing TRAINING RECORD BOOK from
being used for illegal purposes by other persons;

5. That I execute this affidavit to attest to the truth of all the foregoing facts and for securing
a new TRAINING RECORD BOOK.

Affiant further says none.

IN WITNESS WHEREOF, I have hereunto set my hand this 5th day of June 2016 in Villa
Arevalo, Iloilo City, Philippines.

____________________________

Affiant
________________________________________

________________________________________

BEFORE ME, appears the person of ELLEN A. ADARNA

presenting the above Affidavit, who is personally known to me or identified by

me through competent evidence of identity as defined by the Notarial Rules as

the person who signs the document and in my presence taken an oath or

affirmation before me as to such document.

WITNESS MY HAND AND SEAL this 8th day of January, 2014 in

Imus City, Cavite

Doc. No. ____;

Page No. ____;

Book No. ____;

Series of 2014.