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Affidavit of Loss for Form 138

1. Nica Ella Masangkay-Laksamana graduated from Sumulong Memorial High School in 2010 and was issued Form 138 (Report Card) but discovered its loss on May 3, 2022 after diligent search. 2. She executed an affidavit to attest to the loss of Form 138 and request a replacement copy as she intends to continue her studies. 3. The affidavit was signed and sworn before a notary public in Rizal, Philippines.

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Nhez Lacsamana
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1K views1 page

Affidavit of Loss for Form 138

1. Nica Ella Masangkay-Laksamana graduated from Sumulong Memorial High School in 2010 and was issued Form 138 (Report Card) but discovered its loss on May 3, 2022 after diligent search. 2. She executed an affidavit to attest to the loss of Form 138 and request a replacement copy as she intends to continue her studies. 3. The affidavit was signed and sworn before a notary public in Rizal, Philippines.

Uploaded by

Nhez Lacsamana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines)

City of __________________  ) S.S.


 
 
AFFIDAVIT OF LOSS
 
 
I, NICA ELLA MASANGKAY-LAKSAMANA, married, of legal age,
Filipino, residing at No. 13 C. Lawis Extension, Brgy. Dela Paz, Antipolo City,
after being duly sworn to in accordance with law, do hereby depose and say
that:
 
1.    I finished my secondary (high school) education at the Sumulong
Memorial High School and graduated thereat in 2010;
 
2.    As such, said school issued my Form 138 (Report Card);
 
3.    Last 3 May 2022, I discovered the loss of the said Form 138 from
among my belongings;
 
4.    Efforts were exerted to locate and recover the said high school
diploma, but in spite of diligent search, the same cannot be located
and is now beyond recovery;
 
5.    In the event that the said high school diploma should hereafter be
found or recovered, I undertake to forward or surrender the same to
the said school, for its appropriate disposal; and,
 
6.    I am executing this Affidavit to attest to the truth of the foregoing  and
to support a request for replacement copy of the abovementioned
Form 138 in connection with my intention to continue my study. 
 
 
IN WITNESS WHEREOF, I have hereunto affixed my signature
this __________ day of _________________, at ______________________, Philippines.

NICA ELLA MASANGKAY-LAKSAMANA


Affiant

SUBCRIBED AND SWORN TO before me this _________ day of


____________ in _______________, Rizal, Philippines, affiant exhibiting to me her
Voter’s Identification Card with No. VIN: 5802-0069C-D1794NMM20000.

NOTARY PUBLIC
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2022.

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