REPUBLIC OF THE PHILIPPINES ) CITY OF VALENZUELA

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, legal age, married, Filipino with residence and postal address at 1 Villanueva St., Sumilang Subdivision, Dalandanan, Valenzuela City, after having been sworn to in accordance with the law do hereby depose and say; 1. That I am the legal holder/owner of SSS Identification Card issued by the Social Security System; 2. That on November 10, 2011 the said document lost in my possession and might have been misplaced or dropped somewhere; 3. That in spite of diligent effort to locate the aforesaid Identification Card all have been futile; 4. That I executed this affidavit to attest the fact of my statement mentioned above all legal intent and purposes may serve. IN WITNESS WHEREOF I have hereunto set my hand this _____ day of ____________ 2013 at Valenzuela City, Philippines.

JUAN DELA CRUZ Affiant CTC No. ______________ issued on _____________ at ____________________

SUBSCRIBED AND SWORN to before me this _____ day of _____________ 2013 at Valenzuela City, affiant exhibited to me his/her CTC No. Stated below his/her name.

DOC. NO. PAGE NO. BOOK NO. SERIES 2013

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