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I, ANTONIA BELISANA, Filipino, of legal age, single, and a

resident of Indangan, Davao City, after having been sworn to in
accordance with law, depose and say:

1. That I am a bona fide student of University of

Immaculate Concepcion University of Davao City and was issued a
student Identification Card by the said University;

2. That sometime on August 22, 2015, I lost the said

Identification Card issued to me by the said University when I
inadvertently lost it at Mcdo Bangkerohan Branch;

3. That I searched all the places where my Identification Card

might be found but the same could not be anymore located, despite
diligent efforts and I hereby declare that my said Identification Card
was lost beyond recovery;

4. That I execute this Affidavit to attest to the truthfulness of the

foregoing facts and to inform the University of Immaculate
Concepcion of the said loss for purposes of the issuance of a
replacement of the said Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this

25th day of August, 2018 at Davao City, Philippines.


SUBSCRIBED AND SWORN to before me this 25th day of

August, 2018 at Davao City, Philippines, affiant having exhibited to
me her ____________________________.

Notary public

Doc. No. ______;

Page No. _____;
Book No. _____;
Series of 2018.