Republic of the Philippines )

Tacloban City ) S.C.

AFFIDAVIT OF LOSS

I, AAA, of legal age, Filipino, and a resident of Tacloban City, after having been duly
sworn to in accordance with law, hereby depose and state THAT:
1. I am a member of the Social Security System since 2016 and that I am a registered
employer who have been paying my monthly premium up to date;

2. My receipt for my premium payment made on February 6, 2017 applicable for the months
of February and March 2017 with OR/SBR No. 1111111 got lost;

3. The said receipt got lost when we were transferring from our old office to our current one;

4. I requested for the R5 Payments form to provide proof that payments were made, under the
given information above;

5. Despite diligent efforts to locate the aforementioned receipt, it could not be found and the
same is beyond recovery;

6. I am executing this affidavit to attest the fact and truthfulness of the foregoing statements
and for other legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this 11th day of June 2019 at
Tacloban City, Philippines.

AAA
Affiant

SUNSRIBED AND SWORN to before me this 11th day of June 2019 at Tacloban City,
Philippines, affiant having personally shown to me her Unified Multi-Purpose ID with No. CRN-
11111111 as proof of her identity.

Doc. No.
Page No.
Book No.
Series of 2019.