Republic of the Philippines )

City/Municipality of ___________)
Province of __________________) S.S.

AFFIDAVIT

I, _____________________________________________, Filipino, of legal age,

married/single and residing at __________________________________________________,
after having been sworn to in accordance with law hereby depose and state:

1. That I am a holder of SS Card bearing SS Number

________________________/Common Reference Number (CRN)
_________________________ issued by the Social Security System;

2. That last _______________________, I lost the said ID while;

__________________________________________________________________
__________________________________________________________________
_________;

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

4. 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 _________________________.

Book No. : ________;

Page No. : ________;
Doc No. : ________;
Series of 20____.