REPUBLIC OFTHE PIIILIPPINES )

s.s.
Qurzon City )

AFFIDAVIT OF LOSS

t. Filipino, of legal rge, m.rricd/ ringle

tld rctldcnl of , riler hrving been
3woru to lo rccordrme with Lw hcrcby depoce and ray;

Th.t I rm r holdrr of SS Digltizcd ID No' . illucd by thc Socirl S,..urity

Syrtcm; -
Tb.t hit I lort tbc irtd ID *hllc

Th.l lha rtmc couH not b. fouird dcspitc duc dtllS.nt Gtfort to locat€ it;
Thrt I rE crccutlrg thit .rlld.vit to cctttly thc lalt ofthc .bov. documcnt for ahc PurPdc
ofsecurlEg lt! .cplrcarrcll f.om the SSS'

AFFIANT FURTHER SAYETH NAUGH'T..

Afii.nt

SUBSCRIEED AlilD SIYORN td trefore Inc this

Ailtnt erhibltcd to mc hiJbGr CTC No- ban€d on
rt

Iloc. No.
P.8c No.
Book No.
Srrlcr ol