REPUBLIC OF THE PHILIPPINES

CITY OF ____________

) S.S.

AFFIDAVIT OF LOSS

I,
AAA,
Filipino, of legal
age,
single,
and
a
resident of ________________________, after having being duly sworn to
in accordance with law, hereby depose and state that:

1. I was issued a claim stub by the Office of the Registar of the

Polytechnic University of the Philippines (PUP) for my Transcript of
Records (TOR);

2. Despite diligent search and efforts to locate the said claim stub, I
could no longer locate the same such that I now believe that it is
now lost beyond recovery;

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

truth of the foregoing and to support my application for the
issuance of a new claim stub.

IN WITNESS WHEREOF, I have hereunto

this_____________ at ____________________.

set

my

AAA
Government Issued I.D. No. ______________________
Affiant

hand

SUBSCRIBED AND SWORN to before me this ____day of

___________ at _______________, affiant personally appeared and
exhibited to me his government-issued I.D. bearing his photograph and
genuine signature as competent evidence of affiants identity in accordance
with the 2004 Rules on Notarial Practice.
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of 2016.

Notary Public