Republic of the Philippines }

City of }s.s

AFFIDAVIT of LOSS

I,___________________________, of legal age, Filipino, with address at

_________________________________, after having been sworn to in
accordance with law hereby depose and state: That-

1. I am a registered owner and holder of a Social Security

System Identification Card with SSS Number
_____________________;

2. On 29 December 2019, I went to our province at Nambalan

Santa Ignacia, Tarlac City for a short vacation. When we
reached our destination and I was about to leave the bus I
suddenly discovered that I had been a victim of theft, and
upon inspection, found that my wallet was missing which
contained money and several identification cards, including
my SSS ID;

3. Despite diligent efforts to locate the perpetrator and the

missing items, I was unable to find them and they are now
certainly believed to be lost forever;

4. I am executing this affidavit to attest to the truth of the

averments herein contained, as well as for purposes of
securing anew SSS ID in my name, and for all legal intents and
purposes this may serve.

__________________________

SUBSCRIBED AND SWORN to before me this _______________, at

____________, affiant having exhibited to me his ________________________________.

Doc. No. ____;

Page No._____;
Book No._____:
Series of 2020.