REPUBLIC OF THE PHILIPPINES

)
QUEZON CITY
) S.S.

AFFIDAVIT

OF

LOSS

I, RIZA DELA PEA, Filipino, of legal age, married and a

resident of No. No. 13G California Town Homes Katipunan Ave.
San Bartolome Novaliches, Quezon City, after having been duly
sworn to in accordance with law, do hereby depose and state:
1.

That I was duly issued an SSS Identification Card No.

33-6006851-4 by Social Security System;

2.

That sometime of December 2012, I discovered

that the said ID was misplaced and missing;

3.

That I exerted diligent efforts to find the said ID

the same could no longer be found, for which
reason, I am declaring and considering said SSS
I.D. Card as lost; and

4.

That I have executed this Affidavit to attest to

the truth and veracity of all the foregoing for all
legal intents and legitimate purpose this may
serve.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand and
affixed my signature on this 27th day of June, 2013 in Quezon City.

RIZA DELA PEA

Affiant
SUBSCRIBED AND SWORN to before me this 27th day of
June, 2013, at Quezon City. Affiant exhibiting to me her Drivers
License I.D. Card with No. ___________________, issued by the
issued by the Land Transportation Office at East Avenue, Quezon City.
Doc. No._____
Page No._____
Book No._____
Series of 2013.