Republic of the Philippines )

Province of Siquijor )S.S.

Municipality of Larena )

AFFIDAVIT OF LOSS

I, YVONNE CLAIRE JANNE LEGASPI, Filipino, of legal age and a resident of Pari-
an, Enrique Villanueva, Siquijor, after being sworn in accordance with law, hereby state
and declare:

1. That I was a former student of Siquijor State College, Larena, Siquijor;

2. That during my lifetime in the said institution I was able to pay Tuition fees
and other related contributions;
3. That I was issued Official Receipts for those payments made to wit:
1.OR No. 5848222 Tuition 1,000.00
2.OR No. 5890692 Tuition 890.00
Misc fees 860.00
3.OR No.5892125 Tuition 1,000.00
Sticker 6.00
4.OR No. 1535714 Misc fees 3,860.00
Tuition 340
5.OR No. 1537123 Misc Fees (1st Sem) 3,000.00
Tuition 820.00
Graduation Fee 150.00
Diploma 75.00
Yearbook 500.00
Hood Rental 25.00
Toga Rental 50.00

4. That I inadvertently lost/misplaced my own copy of the above-mentioned

Official Receipts and despite diligent efforts exerted just to locate/find the
same, all were in vain;
5. That I am executing this affidavit of loss to attest to the veracity of the
foregoing facts and to request the Office of the Cashier of Siquijor State
College to annotate/record this affidavit of loss on the dorsal portion of the
above-mentioned Official Receipts which is on file in the above-mentioned
office;
6. That finally I am executing this affidavit of loss in all honesty and good faith
and without the intention to mislead/defraud any person, office, body or
entity.

IN WITNESS WHEREOF, I have hereunto set and affixed my signature this ____ day of
April, 2016, at Larena, Siquijor, Philippines.
 YVONNE CLAIRE JANNE LEGASPI
Affiant
ID Number: TIN 478-980-634-000

AND SWORN TO before me this _____ day of April 2016 in Larena, Siquijor Philippines,
affiant exhibiting to me her competent evidence of identity by way of
____________________________________________________________________________________.

Doc. No. _____ ; ATTY. FLORENDO B. OPAY

Page No. _____ ; Until December 31, 2016
Book No. ______; PTR No. 243214
Series of 2016. On: 1-5-2015
Roll No. 39743
IBP No. 04326 Lifetime
MCLE No. V-0000059
June 5, 2013