Republic of the Philippines ))

City of Calbayog )) s.s.

AFFIDAVIT OF LOSS
I, MA PERLA R. VICENTE, Filipino, married, of legal age, and a
resident of Barangay San Policarpo, Calbayog City, Philippines, after having been duly
sworn to in accordance with law, hereby depose and state, that--

1. I am the grandmother and the legal guardian of JOVAN ZAPANTA

VICENTE, 15 years of age and is a bona fide Grade 9 student of San
Policarpo National High School of Calbayog City;

2. As such, he was issued a reference book for Mathematics for Grade 9

sometime in June 2017;

3. Sometime in November 2017, the said book was misplaced somewhere else
and cannot be recalled;

4. After such incident, the he has exerted efforts to locate the same but to no
avail, thus, it was declared lost;

5. I am executing this Affidavit to attest to the truth of the foregoing facts and for
whatever legal purpose this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this 23 rd day of March

2018, at Calbayog City, Samar, Philippines.

MA PERLA R. VICENTE
Affiant
UMID CRN 0033-0771284-9

With conforme:

JOVAN ZAPANTA VICENTE

SUBSCRIBED AND SWORN TO BEFORE ME, this 23rd day of March 2018
in the City of Calbayog, Samar, Philippines.

ATTY. ALJUN B. DIAZ

Public Attorney I
Pursuant to RA 9406

Doc. No. 646;

Page No. 13;
Book No. II
Series of 2018