[Republic of the Philippines ]

[City of Zamboanga ] S.S

X - - - - - - - - - - - - - - - - - - ]

AFFIDAVIT OF LOSS
(RE: SSS ID)

I, JUDITH F. DACUBA, of legal age, Filipino, with

residence and postal address at Sangali, Zamboanga
City, Philippines, under oath, do hereby depose and
say:

That I am a member of the Social Security System

(SSS), Zamboanga City, with SSS number 001007500706;

That in lieu thereof, I was issued a membership

identification card by the said institution;

That unfortunately however sometime last year, I

discovered that my said identification card was missing
from my possession probably misplaced;

That diligent efforts were exerted to locate the

said SSS membership identification card but to no avail
hence the same is now considered lost and beyond
recovery;

That I am executing this affidavit to attest to the

veracity of the foregoing facts and for all legal
intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand

this __________________ in the City of Zamboanga,
Philippines.

JUDITH F. DACUBA
Affiant

SUBSCRIBED AND SWORN to before me this

________________ in the City of Zamboanga, Philippines.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2013.