REPUBLIC OF THE PHILIPPINES )

Province of Tarlac ) S.S.

x----------------------------x

AFFIDAVIT OF LOSS
I, _______________________, of legal age, single, Filipino, and with residence
at ____________________________________________________________________,
having been duly sworn in accordance with law, hereby depose and state:

1. That I am the bona fide owner of a Gate Pass ID issued by the Holy
Cross College (HCC) located at Concepcion, Tarlac, Philippines;

2. That on _______________________, I lost the above-mentioned Gate Pass

ID issued by the Holy Cross College (HCC), which I last saw at my
pocket, where I usually kept the same;

3. That I was only able to report the LOSS at this time since I was hoping
to find the aforementioned Gate Pass ID issued by the Holy Cross
College (HCC);

4. That I have not seen nor found the said Gate Pass ID issued by the Holy
Cross College (HCC) as of the date of execution of this affidavit, and I
do not expect to recover the same; and

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

the foregoing narrated facts, to be issued a new Identification Card by
the Holy Cross College (HCC), and for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________________ at Concepcion, Tarlac, Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me, this _____________________, by the

Affiant who has satisfactorily proven his identity to me through his
___________________________________________________________________________to be
the same person who executed and personally signed this document.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of ______.