REPUBLIC OF THE PHILIPPINES }

___________________ } S.S.

AFFIDAVIT OF LOSS

I, ________________________, of legal age, Filipino and with residence at

______________________, after having been duly sworn to in accordance with law
hereby depose and state that:

1. I am a member of the Social Security System (SSS) and was issued an ID

card by the Social Security System Office of Caloocan;

2. I used to place the said SSS ID card together with other important

3. That I regularly keep the said ID in my wallet, among others;

4. That sometime on Sometime on January 2010, when I arrived home from

work, I discovered that said ID card was no longer in my wallet;

5. That for all legal intents and purposes the said Identification Card is now
considered lost and beyond recovery;

6. That I am executing this affidavit to attest to the truth of the foregoing

facts.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of

March 2019 at Paniqui, Tarlac, Philippines.

                                                                                            __________________________
___
                                                                                      Affiant

SUBSCRIBED AND SWORN TO before me, this 18th day of March, 2019 at
Paniqui, Tarlac.

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