REPUBLIC OF THE PHILIPPINES)CITY OF NAGA CITY                      ) S.S.x-------------------------------------x  

AFFIDAVIT OF LOSS 

         I, MARK ANTHONY R. TALLO, of legal age, Filipino, single and a resident of Bolo Norte, Sipocot Camarines Sur, after having been duly sworn to in accordance with law, depose and state:

1. That I am a holder of Form 138 duly issued in my favor by Bolo Norte, Highschool on March 30, 2007 in the said school;

2. That I used to put said report card in my bag;

3. That sometime on April 20, 2014, when I arrived home from looking for a job, I discovered that said report card was no longer in my bag;

4. That diligent effort to locate the same proved futile;

5. That in view thereof, I now desire and hereby request to a new report card in lieu of the lost one;

6. That I bind myself to save the said school of the harmless from any loss or damage that it may incur in connection with the issuance of a new report card in lieu of the lost one;

7. That I am executing this affidavit to attest to the foregoing facts and for any legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of March. 2016 at Bolo Norte, Sipocot Camarines Sur.                                                                   Name Over Signature of Affiant                                                             SUBSCRIBED AND SWORN to before me, this ____ day of ______________, 20___ in ___________________ City, with affiant exhibiting his CTC No. _______________ ,Issued on ______________________ at _________________________.  

Doc.  No. :  ________;Page  No. :  ________;Book No. :  ________;Series of 20___.