Republic of the Philippines)

La Trinidad, Benguet) s.s

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AFFIDAVIT OF LOSS

I, NOEL ED JAY SOBEJANA DE LEON, of legal age, Filipino, and resident of 16-
B SCT Santiago St., Roces Avenue, Quezon City, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and state THAT:

1. I am a bonafide holder of a Unified Multi-Purpose (UMP) ID card duly issued

by Social Security System (SSS);

2. However, sometime on December 2016, I boarded a bus from Baguio City

going to Manila. That time, along with me is my wallet containing my said
UMP ID card. Unfortunately, when we were at the bus terminal in Cubao,
Quezon City, I noticed that my said wallet inside my back pocket of my pant is
missing. I discovered that my pocket where my said wallet was kept was cut
as a means of stealing the wallet. In view thereof, I therefore considered my
said UMP ID Card as have been lost and beyond recovery;

3. My said UMP ID Card has neither been used for any illegal activities nor
confiscated by any government authorities but due to the afore cited reason;

4. I am executing this Affidavit to plead and request the office of the Social
Security System (SSS) to issue me a new UMP ID Card in lieu of the lost one.
That, I hereby bind myself to fully excuse the SSS for any damage that it may
incur for the issuance of the requested ID Card;

5. Finally, I am executing this affidavit to attest to the truthfulness of the

foregoing facts and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 1st day of February
2017 at La Trinidad, Benguet, Philippines.

NOEL ED JAY SOBEJANA DE LEON

Affiant
Driv. Lic. No. N02-10-018655
Valid until 2016-08-19

SUBSCRIBED AND SWORN to before me a Notary Public for and in La Trinidad,

Benguet, Philippines this 1st day of February 2017 by the above Affiant exhibiting to me his
ID with picture above his name and identified by to be the same person who personally
signed before me the foregoing Affidavit.

ATTY. CYRUS C. CALAYA

Doc. No. 369; Notary Public until Dec. 31, 2017
Page No. 74; PTR No. BGT 4620292; January 29, 2016
Book No. I; IBP Lifetime No. 08051, at Pasig City
Series of 2017. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4
National, Highway La Trinidad, Benguet