Republic of the Philippines}

City of Antipolo} S.S.

AFFIDAVIT OF LOSS
I, Maria Jean A. Moleno-Rodriguez, of legal age, single, with residence and postal address at
Blk 4 Lt 1 St. Mary Street, Our Lady of Fatima Village, Brgy San Isidro, Antipolo City 1870,
after being sworn in accordance with law, depose and say that:

1. I had been an employee of Citibank N.A. from 2007 up to 2013, with an office at 32nd St.,

Bonifacio Global City, Taguig City;

2. As such, I was provided by our employer with several Identification Cards such as our

Company ID, PHILHEALTH ID, Citi ATM Card and I was likewise required to procure our

SSS Identification Card, bearing my single name – Maria Jean A. Moleno;

3. Way back in 2013, I got hired as a Manager at Citibank Hong Kong which then requires

me to go abroad, and bring all my required necessities and luggage, including my daily

purse in which my wallet containing the aforementioned IDENTIFICATION CARDS;

4. However, due to numerous transfers done in the last years, back forth between

Philippines and Hong Kong, I was surprised one day that I couldn’t find my SSS

identification card anymore and was lost, probably due to a lot of transfers amongst my

bags through the years;

5. Diligent efforts have already been exerted to retrieve my wallet along with this ID, but all

turned out futile, as I had turned all my bags and wallets inside out, but couldn’t find it;

6. I have to request for the issuance of the new national ID, in my new married name –

Maria Jean M. Rodriguez, in furtherance of my personal transactions and such other

business transactions which may require the presentation of this aforementioned

missing ID;

7. This affidavit is being executed to attest to the veracity of the foregoing facts and for

whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

November 5, 2019, Antipolo City

Maria Jean A. Moleno-Rodriguez

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________ at____________,

Philippines, affiant exhibiting to me her CTC _________________, issued at Manila, on
___________________.

NOTARY PUBLIC
DOC. NO._____;
PAGE NO._____;
BOOK NO._____;
SERIES OF _____.