REPUBLIC OF THE PHILIPPINES)

City of Santiago) S.S.

AFFIDAVIT OF UNDERTAKING

I, MAGDALENA M DELA CRUZ, Filipino, married, of legal age and a resident of

168 Carreon St., Centro East, Santiago City, after being sworn in accordance with law
hereby depose and state—

1. That I am an active member of the Social Security System having its Main
Office Address at SSS Building East Avenue, Diliman Quezon City,
Philippines ;

2. That upon membership, I was issued SS Number 01-2015800-7 and CRN

Number 0111-7299827-2 by the aforesaid entity;

3. That

4. That

5. That despite diligent search and efforts to locate the said wallet and my
Driver's License and my ATM Card, I could not find them such that I now
believe that they are now lost beyond recovery

6. That my Driver's License has not been confiscated by the LTO, Police or
other Traffic Enforcers for any traffic violation.

7. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the issuance of a new Driver's
License and a new ATM Card, in lieu of the ones that were lost.

IN WITNESS WHEREOF, I set my hand this 23rd day of July 2019 at Santiago
City, Philippines.

CRISTOPHER IAN J DAR

Affiant
CTC No. 12591091
Contact Number: 09358887925

SUBSCRIBED AND SWORN to before me this 23rd day of July, 2019 at

Santiago City, Philippines, affiant exhibiting to me his Community Tax Certificate No.
12591091 issued on February 21, 2019 at San Mateo, Isabela.

Doc. No.
Page No.
Book No.
Series No.