AFFIDAVIT AND INDEMNITY BOND FOR A LOST ACADEMIC CERTIFICATE

PART A — AFFIDAVIT OF LOSS

I, __________, __________, resident of __________, do hereby solemnly affirm and declare as under:

1. 7. That the said certificate has not been pledged, deposited, mortgaged or transferred to any person or institution, and remains untraced despite the efforts stated above.

1. 8. That this affidavit is sworn in support of an application for issuance of a duplicate certificate in place of the one lost.

1. 9. That the contents of this affidavit are true and correct to my knowledge and belief, that no part of it is false and that nothing material has been concealed therefrom.

VERIFICATION

DEPONENT

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PART B — INDEMNITY BOND

1. 12. That I shall be solely responsible for any consequence arising from any false statement made in Part A above.

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Witness 1: _________________    Witness 2: _________________