Republic of the Philippines)

La Trinidad, Benguet) s.s

x- - - - - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, Brendally G. Saliw-an, of legal age, married, Filipino, and a resident of No.

AD110 F WindyHill, Buyagan, La Trinidad, Benguet after having been duly sworn to in
accordance with law, do hereby dispose and state THAT:

1. I am a bonafide holder of SSS ID dully issued by the Social Security System.

The said ID card was kept inside my wallet which was under my shoulder
bag;

2. The said ID card were lost/missing sometime on September 2019 somewhere

at Session Road, Baguio City;

3. The particular facts of loss of the afore-mentioned ID are as follows:

Sometime on September 2019, I went to Session Road along with me were
the aforementioned SSS ID inside my shoulder bag, while walking, I check
my shoulder bag and I noticed that my wallet were missing. Then and there I
searched on the other side pocket of my shoulder bag but the same was also
not there;

4. Immediately, I searched for the said wallet in the premises, but the same is
nowhere to be found

5. Despite my earnest efforts to locate or find my afore-mentioned wallet,

however, my efforts prove futile. I therefore considered the same loss and
beyond recovery;

6. I hereby attest that the said SSS ID were not used for any illegal or unlawful
purposes but due solely to the foregoing reasons;

7. I am executing this Affidavit to request the Social Security System to issue a

new SSS ID in lieu of the lost one. That, I hereby bind myself to fully excuse
the Social Security System (SSS) for any damage or liability that it may incur
for the issuance of the requested SSS ID;

8. Finally, I am executing this affidavit to attest to the truthfulness of the

foregoing facts and for all legal intents and purposes it may serve well.

IN WITNESS WHEREOF, I have hereunto set my hand this 17 th day of

October 2019 at La Trinidad, Benguet, Philippines.

Brendally G. Saliw-an
Affiant
TIN No. 467-407-614

SUBSCRIBED AND SWORN to before me a Notary Public for and in La

Trinidad, Benguet, Philippines this 17 th day of October 2019 by the above affiant,
personally known to me and appeared before me and voluntarily signed the same.

ATTY. CYRUS C. CALAYA

Doc. No. 293; Notary Public until Dec. 31, 2019
Page No. 57; PTR No. BGT 5358129, Jan. 4, 2019
Book No. VI; IBP Lifetime No. 08051, at Pasig City
Series of 2019. Roll No. 52590, May 12, 2006; Manila
S & B Bldg., FA 224, Km. 4, La Trinidad, Benguet