Affidavit of Loss - Form 137

 

REPUBLIC OF THE REPUBLIC THE PHILIPPI PHILIPPINES NES ) Province of Leyte ) S.S. Municipaity of !ia"a ) #$$$$$$$$ $$$$$$$$$$$ $$$$$$#  

AFFIDAVIT AFFIDAV IT OF LO LOSS SS

%OF FORM &'() I MIRA Fiipi pino no of e e*a *a a* a*e e +i +in* n*ee an an, , a re re+i +i,en ,entt of Si Siti tio o MIRAFLO FLOR R E. IMP IMPOC OC  Fii Si-"oryo Br*y. Fati-a !ia"a Leyte Piippine+ after "ein* ,uy +/orn to in accor,ance /it a/ ere"y ,epo+e an, +tate tat0 &. So-eti-e So-eti-e a+t a+t -ont or on on May 12&( I +u"-itte, +u"-itte, -y appication appication for for *ra,uation *ra,uation to to te Univer+ity Re*i+trar of te !i+aya+ State Univer+ity %!SU) 3 !i !ia"a a"a Ca-pu+4 1. 5ay+ after after I /a+ /a+ appri+e, appri+e, "y te Univer+ity Univer+ity Re*i+trar Re*i+trar of !SU$! !SU$!i ia"a a"a Ca-pu+ tat tat I ac6e, te re7uire, Form 137 i++ue, "y !ia"a !ocationa Hi* Scoo4 '. I oo oo6e 6e, , for for tte e +ai +ai, , Form 137 "ut to no avai. Sai, Form 137 to*eter /it -y oter ot er i-p i-port ortant ant ,ocu-en ,ocu-ent+ t+ *ot o+t o+t "ecau+e "ecau+e of Typo Typoon on 8oan,a an,a tat tat it our   province +o-eti-e on Nove-"er 12&'4 9. Tat Tat ,e+pite ,e+pite ,ii*e ,ii*ent nt +earc +earc an, effort effort++ to ocate ocate te +ai, Form it +uc tat I no/ "eieve tat it i+ no/ o+t "eyon, recovery4 5.

137

I cou, not fin,

:+ +uc I a- e#ecutin* ti+ :ffi,avit of Lo++ to atte+t to te trut of te fore*oin* to +upport -y appication for *ra,uation /it !SU$!ia"a !SU$!ia"a Ca-pu+ an, for /atever  e*a purpo+e tat ti+ :ffi,avit -ay +erve.

IN WITNESS WHEREOF

I ave ereunto +et -y an, ti+ 1 n, ,ay of ;une 12&( at

!ia"a !ia"a Leyte Piippine+.