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Jan 19, 2010

Republic of the Philippines )
City of ___________________ ) S.S.


I, ________, of legal age, single, Filipino and resident of ___________, Philippines, after having been duly sworn in accordance with law, do hereby depose and say:

  1. That I am a bona fide student of the University of ______________;
  2. That as such, I was issued a Student Identification Card with I.D. No. _______;
  3. That some time on _________, (state the circumstances of the loss);
  4. That, despite diligent efforts to locate the said I.D., the same could not be found;
  5. That my Student Identification Card is now lost and beyond recovery;
  6. That I am executing this affidavit to attest to the truth of the foregoing and to facilitate the replacement of my lost Student Identification Card.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ______, in _____, Philippines.


SUBSCRIBED AND SWORN to before me, this _____th day of _________ in ______, Philippines, affiant exhibiting to me his (personal identification) issued on _______ at ___________, Philippines.

Notary Public

(NOTA BENE: The portion in blue font is referred to as the "Jurat." It often accompanies affidavits but is not considered part of it.)


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