AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, _______________________, of legal age, Filipino, and a resident of

_______________________________________________________________, after having been
sworn in accordance with law, hereby deposes and states the following:

1. I am holder of a Philippine SSS Identification card with SSS number

____________________.
2. I have discovered that said item is lost and can no longer be found despite diligent efforts
to locate the same;
3. I have to request for re-issuance of my SSS Identification Card for personal and other
business transactions which may require presentation of the aforementioned ID Card.
4. This affidavit is executed to attest the veracity of the foregoing facts and for whatever legal
purpose it may serve.

Signed on the date and at the place indicated below.

_______________________
__

Affiant

SUBSCRIBED and SWORN TO before me on the date and at the place indicated below. The
affiant exhibited to me his competent evidence of identity as indicated above.

Signed this _____________________ at ________________________, Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No.

Page No.

Book No.

Series of 2018