REPUBLIC OF THE PHILIPPINES) _________________)

S.S.

AFFIDAVIT OF LOSS

That I, CHONA G. SUMALINOG of legal age, Filipino citizen, widowed with

residence and postal address at 398-H, Sitio ISKP, Sambag-2, Cebu City, after having been duly
sworn to in accordance with the law do hereby depose and say:

That I am the legitimate spouse of the late OLIVER M. SUMALINOG an SSS member
who passed away last April 13, 2020;

That the said SSS member lost his SSS I.D. sometime in the year 2018 with SSS number
06-19561561;

That despite of diligent effort has been made to look for the said item mentioned above
but proved futile and must therefore considered it lost for all intents and purpose;

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

IN WITNESS WHEREOF, I hereunto set my hand on this ___day of___________2020

in the City of Cebu, Philippines

____________________________
Affiant

SUBCRIBED AND SWORN to before me on this ____ day of ____________ 2020, in

the City of Cebu, Philippines.

Doc. No.________
Page No. ________
Book No. ________
Series of Year_____