REPUBLIC OF THE PHILIPPINES)

Mandaue City )S.S.

AFFIDAVIT OF LOSS

I, LORNA G. CABATINGAN, of legal age, Filipino and a resident

of L.C. Cabrera St. Casuntingan, Mandaue City, after having been
sworn to in accordance with law, hereby depose and say that:

1. That I was issued an SSS I.D. bearing the numbers 06-

0942989-1 by the Social Security System;

2. That sometime this year, I misplaced the said SSS I.D.;

3. That the said SSS I.D. could not be found despite diligent
efforts to locate the same;

4. That I am executing this affidavit for the issuance of a new

SSS I.D., to attest to the truth of the foregoing facts, and for whatever
legal purpose this may serve;

4. Affiant further sayeth naught.

Signed this ___ day of ____________, 2018 at Mandaue City,

Philippines.

LORNA G. CABATINGAN
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ___________

2018 in Mandaue City, affiant exhibiting to me her TIN ID 143-236-450
as competent evidence of her identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.