REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF LOSS

I, , of legal age, Filipino, and with address at ___________________________,

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

1. I am a faculty member of ) and have been regularly receiving my

monthly compensation with the same.

2. On every 15th and 30th of the month, I received my salary through an ATM
and thereafter my Payslips for the months of November 2016 to June 2017. These
Payslips was kept in my belongings at the drawer of my office table.

3. On __ August 2017, I discovered that the said Payslips was lost among my
belongings. I exerted all efforts to locate the same but all to no avail.

4. I am executing this Affidavit to attest to the truthfulness of all the

allegations therein and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

______ August 2017 at _______________.

Affiant
 SUBSCRIBED AND SWORN to before me this __ day of August 2017 at
_______________, affiant exhibited to me with her _____________________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.