REPUBLIC OF THE PHILIPPINES)

___________________) S.S.

AFFIDAVIT OF LOSS

That I, ______________________________________ of legal age, Filipino citizen,

single with residence and postal address at ___________________________________________
______________________________________________________________, after having duly
sworn to in accordance with the law do hereby depose and say:

That I am the owner and in possession of SSS I.D. with number _________________
issued by Social Security System (SSS);

That the aforesaid SSS I.D. was lost due to unavoidable circumstances when it was
unfortunately misplaced;

That despite of diligent effort has been made to look for the said item mentioned above but
proved futile and must therefore considered it lost for all intents and purposes.

That I am executing this affidavit to attest to the truth of foregoing facts and to inform the
proper authorities concern and for whatever legal purpose this affidavit may serve.

IN WITNESS WHEREOF, I hereunto set my hand on this ___ day of ________, 20__, in
the City of _______.

_________________________________
(PRINTED NAME AND SIGNATURE)
Affiant

SUBSCRIBED AND SWORN to before me on this this ___ day of _____ 20__, in the City
of _______.

Doc. No.
Page No. Notary Public
Book No.
Series of Year