Republic of the Philippines )

City/Municipality of ___________)

Province of __________________) S.S.

AFFIDAVIT OF LOSS

I, _____________________________________________, Filipino, of legal age,

married/single and residing at __________________________________________________,

after having been sworn to in accordance with law hereby depose and state:

That I am a holder of SS Card bearing SS Number

________________________/Common Reference Number (CRN)

_________________________ issued by the Social Security System;

That last _______________________, I lost the said ID while

__________________________________________________________________

__________________________________________________________________

_________;

That the same could not be found despite diligent efforts to locate it;

That I am executing this affidavit to certify the loss of the above-mentioned ID for

the purpose of securing its replacement from the SSS.

AFFIANT FURTHER SAYETH NAUGHT.

SIGNATURE OVER PRINTED NAME

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______________, 20___ in

___________________ City, with affiant exhibiting his/her CTC No. ____________________,

issued on ______________________ at _________________________.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;

Book No. : ________;

Series of 20____.