REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS
I, GERALD ALFRED D. GARIBAY, 17 years old, Filipino, single and a
resident of Bacolod City, after having been duly sworn to in
accordance
with
law,
depose
and
state THAT:
1. I am
a
____________________
student
________________ in Bacolod City College;

taking

up

2. Sometime on ____________, my library card was misplaced and

got lost;

3. Efforts were exerted to locate said library card, but in spite of

diligent search, it could not be found and the same is now
beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to comply with the requirements for
my enrollment in Bacolod City College
IN WITNESS WHEREOF, I have hereunto set my hand
this ___________________ in
Bacolod City,
Metro
Manila, Philippines.

GERALD ALFRED D. GARIBAY

Affiant
SUBCRIBED AND SWORN TO before me this 9th day of
November 2016 in Bacolod City, Philippines, affiant exhibiting to
me his/her
competent
evidence
of
identity
by
way
of
__________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2016.