Republic of the Philippines)

Davao City ) S.S

AFFIDAVIT OF LOSS

I, Lucia O. Lozada, of legal age, Filipino citizen, single, and with residence at Panacan,
Davao City, after having duly sworn to in accordance with law hereby depose and say:

1. That I am the owner and in possession of SSS I.D. with number __________
issued by Social Security System (SSS);

2. That the aforesaid SSS I.D. was lost due to unavoidable circumstances when it
was unfortunately misplaced;

3. That diligent effort has been made to look for the said item mentioned above but
proved futile and must therefore considered it lost or all intents and purposes;

4. That I am executing this affidavit to attest to the truth of the foregoing facts and to
inform the proper authorities concerned and for whatever legal purpose this
affidavit may serve.

IN WITNESS WHEREOF, I hereunto set my hand on _________________ in Davao City,

Philippines.

LUCIA O.
LOZADA
Affiant

SUBSCRIBED AND SWORN to before me on ___________________ at Davao City,

Philippines, affiant exhibited to me her _____________ as her competent evidence of identity.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2023.