Republic of the Philippines)

Roxas City ) S.S.

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AFFIDAVIT OF LOSS

I, KHRISNA DELA TORRE, of legal age, Filipino, single, and a

resident of Brgy. Jaena Sur, Jamindan, Capiz Philippines, after being sworn
to in accordance with law, depose and say:

1. I am an incoming BS Criminology- Fourth Year Student of Capiz

State University-Dayao Campus, Dayao, Roxas City, Capiz.

2. When I was a Third Year Student, I have paid all my school fees
and was issued an Exam Permit to take the Final Exam for the
Second Semester, S.Y. 2018-2019.

3. The above-mentioned Exam Permit were compiled in a Folder for

safekeeping but, recently, when I looked for the said exam
permit that was issued to me, I cannot find the same.

4. After such discovery, I exerted efforts earnest efforts to locate

and find the same, but the same proved futile and fruitless.

5. I am executing this affidavit under pain of perjury to attest to the

truth and veracity of the foregoing statements and for other
legal purpose this affidavit may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________

in the City of Roxas, Capiz, Philippines.

KHRISNA DELA TORRE

Affiant

The Affiant, whose name and personal circumstances are stated

above, appeared in person before me this __________________, in the City of
Roxas presented the above instrument, signed the same in my presence,
and affirmed or swore under oath to the truth and correctness of the
contents or allegations of the same. The affiant was personally known to
me and she exhibited to me her __________________.

Doc No. _________

Page No. ________
Book No. ________
Series of 2019