AFFIDAVIT OF LOSS (of UMID)

I, ______________________________, of legal age, Filipino, and with present

address at ___________________________________________, Taiwan, after having
been sworn in accordance with law, do hereby depose and state that:

1. I am a holder/owner/ of UMID with CRN ________________ which was

issued to me by the Social Security System (SSS);

2. Sometime in _________________, I have discovered that the said UMID

is lost and can no longer be found despite exerting diligent efforts to
locate the same; and

3. I execute this affidavit to attest to the truth of the foregoing and for
other legal purpose this may serve.

IN WITNESS WHEREOF, I hereby affix my signature this

_____________________ in Taipei City, Taiwan.

____________________________
Affiant

MANILA ECONOMIC AND CULTURAL OFFICE, TAIPEI, TAIWAN

SUBSCRIBED and SWORN to before me this _____________________, at Taipei

City, Taiwan by _____________________________________________, who is known to me
by competent evidence of identity consisting of her/his ______________________________
with No. _____________________ issued by __________________ on ________________
and valid until ___________________.

WITNESS MY HAND AND SEAL of the Manila Economic and Cultural Office on the
date and place above-mentioned.

Series of 20 __________
Service No.___________ Upon request and authority of the
Fee Paid-NT$_________ Department of Foreign Affairs
M.R/P.R. No._________ Republic of the Philippines