Republic of the Philippines )

City of Taguig, Metro Manila) S.S.

AFFIDAVIT OF LOSS

I, DIZA MONGAO DURIMON, of legal age, Filipino Citizen, with residence and
postal address at #2 Purok 6-C, Daisy St., Lower Bicutan, Taguig City, Metro Manila, after
having duly sworn to in accordance with law do hereby depose and state:

That I am a member of the Social Security System, thus, was issued my SSS
Digitized ID Card bearing SSS No.33-4469321-9;

That sometime on December 2013, while looking for the aforesaid SSS Digitized ID
card in my wallet where it was usually kept, I could no longer find the same, probably was
misplaced;

That I exerted all efforts to locate or find the said SSS Digitized ID Card, but proved
futile and meaningless whatsoever;

That I am executing this AFFIDAVIT to attest to the truth and veracity of the above
statements for all LEGAL INTENTS and PURPOSES it may serve best.

IN WITNESS HEREOF, I have hereunto signed my name this 4 th day of February

2015 at City of Taguig, Metro Manila.

DIZA MONGAO DURIMON

Affiant

SUBSCRIBED & SWORN TO BEFORE ME this 4th day of February 2015 at City of
Taguig, Metro Manila, affiant exhibiting to me her Passport with No. EB0473606 issued by
DFA, valid until June 25, 2015.

Doc. No. ____

Page No. ____
Book No. III .
Series of 2015.