REPUBLIC OF THE PHILIPPINES ) S.S.

______________________________)

AFFIDAVIT OF LOSS

I, _____________________, Filipino, of legal age, single and a resident of No.

_______________________________, after having been duly sworn in accordance with
law, hereby voluntarily depose and state THAT:

1.0. I am a bona fide member of Security Services System (SSS) and holder of SSS ID
No. ____________________ issued in my favor by SSS,
_____________________ Branch.

2.0. On _____________________, while I was on my way to

_____________________ to deliver documents, I discovered that my SSS ID was
missing and no longer inside my pocket.

3.0. To date, despite diligence efforts to find said SSS ID, I was not able to locate the
same.

4.0. I am executing this affidavit to attest to the truth of all the foregoing and for the
issuance of a new SSS Identification Card in my name, and for whatever legal
purpose this may serve.

IN TRUTH WHEREOF, I have hereunto signed my name below, this _________

of _____________________, at _______________.

_____________________
Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of

____________________ _2023 at ______________, affiant personally appeared with
Community Tax Cert. No. ______________, issued on ___________ at
______________.

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