AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

CITY OF IMUS) S.S.

I, ____________, Filipino, of legal age, residing at B9 L9 Kimberton Ville Niog 2, Bacoor

City, after having been sworn in accordance with law hereby depose and state:

That sometime in June of this year, I was looking for my original

Transcript of Records but to my surprise, said original Copy could not
found;

That I took pains to look for said Transcript of Records, but to no

avail;

That I am executing this affidavit to attest to the truth of the

foregoing and to request from the ________________________ to issue
a copy of the said Transcript of Records.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

_______________. 2017___ at _________________________.

MR. X

SUBSCRIBED AND SWORN to before me, this ____ day of ______________,

20___ in ___________________ City, with affiant exhibiting his CTC No.
_______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC
Until December 31, 2007___

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.