Republic of the Philippines

CAGAYAN STATE UNIVERSITY

OFFICE OF STUDENT SERVICES & WELFARE
Control Number: __________

AFFIDAVIT OF LOSS
Name:
___________________________________________________________
_________________________
Year: ________ Course: __________________ College: ____________________
________________

ID
Date

No.:
of

loss:

I, whose name appears above, do hereby declare that I lost my University Student ID Card
and am unable to locate it despite my greatest effort.
_________________________________
Name and Signature of Student

___________________
Date Signed

I hereby attest that the student whose name appears above is a bona fide student enrolled
in the College:
________________________________
College Dean
Noted:
EDITHA S. PAGULAYAN, D.P.A.
Director, Student Services and Welfare
F-OSSW-2601

Rev. 1, January 2016