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REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD ) S.S.


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AFFIDAVIT OF LOSS

I, HANNAH M. APSAY, of legal age, single, Filipino and a resident of Brgy. Cabug,
Bacolod City, Philippines, after having sworn to in accordance with law, hereby depose and
state that:

1. I am a bona fide student of the Bacolod City College Bacolod City, and as such, I was
issued an enrollment form;

2. That recently when I looked for the said enrollment form, the same could not be found
in the place where I usually keep it;

3. The said enrollment documents could have been misplaced or inadvertently fallen
from my wallet sometime that I cannot recall;

4. After efforts to locate the same proved futile, it is now safe to conclude that the
enrollment form is lost beyond recovery;

5. Thus, I execute this affidavit to attest to the truth of the foregoing facts in support of
my application for the issuance a new enrollment form for whatever legal purposes
this affidavit may accordingly serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________________at the


City of Bacolod, Philippines.

HANNAH M. APSAY
Affiant

SUBSCRIBED AND SWORN to before me this ________________________ at Bacolod City,


Philippines, with student identification No. 15-0522 who executed this affidavit voluntarily.

Doc No. _______


Page No._______
Book No._______
Series of 2017