Affidavit of Loss - Form 138

REPUBLIC REPUBLIC OF THE THE PHILIPPI PHILIPPINES NES ) Province of Leyte ) S. S. Municipaity of !ia"a ) #$$$$$$$$ $$$$$$$$$$$ $$$$$$#

AFFIDAVIT AFFIDAVIT OF LOSS L OSS

I% NELSIE LAPORE % Fiipino% of e&a a&e% 'in&e an( a re'i(ent of Br&y. Ca&nocot% !ia"a% Leyte% Piippine'% after "ein& (uy '*orn to in accor(ance *it a*% ere"y (epo'e an( 'tate tat+ ,. On Fe"ruary Fe"ruary -% -/,0% I 'u"1itte 'u"1itte( ( 1y appica appicatio tion n for &ra(uat &ra(uation ion to te Univer'i Univer'ity ty Re&i'trar of te !i'aya' !i'aya' State Univer'ity 2!SU) 3 !ia"a Ca1pu'4 -. On 5pri 5pri 6% -/,0% I *a' appri' appri'e( e( "y te Univer'ity Univer'ity Re&i'tr Re&i'trar ar of !SU$!i !SU$!ia"a a"a Ca1pu' Ca1pu' tat I ac7e( For1 ,6% a re8uire( piece of (ocu1ent for &ra(uation4 6. On te 'a1e 'a1e (ay% (ay% I oo7e( oo7e( for 1y For1 ,6 ,6 "ut to no no avai. avai. Sai( For1 For1 ,6% to&eter  to&eter  *it 1y oter i1portant (ocu1ent'% &ot o't "ecau'e of Typoon 9oan(a 9oan(a tat it our   province 'o1eti1e on Nove1"er -/,64 :. Tat (e'pite (e'pite (ii&ent (ii&ent 'earc 'earc an( effort' effort' to ocate ocate te 'ai( 'ai( For1 ,6% I cou( cou( not fin( fin( it 'uc tat I no* "eieve tat it i' no* o't "eyon( recovery4 5.

5' 'uc% I a1 e#ecutin& ti' 5ffi(avit of Lo'' to atte't to te trut of te fore&oin&% to 'upport 1y appication for &ra(uation *it !SU$!ia"a !SU$!ia"a Ca1pu' an( for *atever  e&a purpo'e tat ti' 5ffi(avit 1ay 'erve.

IN WITNESS WHEREOF %

I ave ereunto 'et 1y an( ti' ,/t (ay of 5pri% -/,0 at

!ia"a% !ia"a% Leyte% Piippine'.

 

;;;;;;;;;;;;;;;;;;;; NELSIE LAPORE  AFFIANT   AFFIANT 

"efore 1e% ti' ,/t (ay of 5pri% -/,0% "y te 5ffiant *o i' per'onay 7no*n to 1e 2or *o1 I ave i(entifie( trou& co1petent evi(ence of i(entity) an( *o e#i"ite( er Scoo I(entification Car( No. !,6$/,$//0< i''ue( at !ia"a% Leyte% Piippine'. SUBSCRIBED AND SWORN  to

 NOT5R  NOT5R9 9 PUBLIC PUBLIC =oc. No. ;;;;;;4 Pa&e No. ;;;;;;4 Boo7 No.;;;;;;4 Serie' of -/,0.