REPUBLIC OF THE PHILIPPINES )

CITY OF CAGAYAN DE ORO ) S.S.

AFFIDAVIT OF LOSS
I, ARSENAL ARSENALL, of legal age, married, Filipino, and a resident of
Piang Puti, Macabalan, Cagayan de Oro, after having been duly sworn to an oath
in accordance with law, hereby depose and say:

That I am the owner of a Social Security System (SSS) Identification Card

with ID No. 08-08765432-9;

That last year, while I was transacting in the SSS Malolo Branch with office
address at Aglipay Building, C-4 Road, Dagat-Dagatan, Malabon City, Manila, I
misplaced and lost the said SSS ID;

That despite efforts to locate the said SSS ID, the same proved to be futile;

That I am executing this Affidavit to attest to the truth of the foregoing and
for whatever purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of April
2019 at Cagayan de Oro, Philippines.

ARSENAL ARSENALL
Affiant

SUBSCRIBED AND SWORN to before me this 24th day of April 2019 at

Cagayan de Oro, affiant exhibiting to me his PhilHealth ID, No. 06 123456789-9,
Philippines.

Doc No.
Page No.
Book No.
Series of 2019.