REPUBLIC OF THE PHILIPPINES )

CITY OF MANDAUE
) S.c.
AFFIDAVIT OF LOSS
I, COLEEN COLINA BALUYOT, 16 years of legal age, single,
Filipino and a resident of Sacred Heart Village, Gun-ob, Lapulapu City,
Cebu, after being sworn to in accordance with law, depose and say that:
1.
I was previously issued a school ID by the University of CebuLM campus;
2.

I used to keep the above-mentioned evidence of identity in my

bag;
3.
Last September 15, 2014, while I was on my way to the doctor
for a check-up, I accidentally left my bag or misplaced it;
4.
I tried all efforts to locate the misplaced bag together with its
contents but I was not able to find it;
5.

The said ID is now beyond recovery; and

6.
I am executing this sworn statement, as required, to enable me
to obtain a replacement for the said lost proof of identity.
IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day
of September 2014, in the City of Mandaue, Philippines.

COLEEN COLINA BALUYOT

Affiant
JURAT
SUBSCRIBED and sworn to before me, this 19 th day of September
2014, in the City of Mandaue by the above-mentioned affiant who is
personally known to herein notary public.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2014.
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