REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAVITE ) S.S.

AFFIDAVIT OF LOSS
  I, REBECCA ROM NON, of legal age, Filipino, and a resident of 213 Taywanak
Ibaba, Alfonso Cavite after having been duly sworn to in accordance with law, depose
and state THAT:

1. I am a bonafide member of Social Security System with SS no. 34 2340829-9 and

I regularly paid my monthly contribution;
 
2. However upon checking my files, I found out just recently that my Payment
receipt for September 2017 was misplaced and cannot be found;
 
3. Despite diligent search and best efforts, I failed to locate and recover the said
receipt to this day;

4. Wherefore, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and for whatever legal purposes that this may serve

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of October,

2022 in Alfonso, Cavite Philippines.

REBECCA ROM NON

Affiant

SUBSCRIBED AND SWORN to before me this 13th day of October, 2022 at

Alfonso, Cavite. Affiant exhibiting to me her TIN:370-000-111-000.

WITNESS MY HAND AND SEAL.

Doc. No. 332; ATTY. ENRIQUE G. BAUTISTA JR.

NOTARY PUBLIC FOR THE PROVINCE OF CAVITE
Page No. 60; COMMISSION EXPIRES ON DECEMBER 31, 2022
Book No. CXIX; ROLL OF ATTORNEY’S NO.52758
PTR NO. 4388970/ISSUED ON 01/17/2022 AT ALFONSO CAVITE
Series of 2022. IBP LIFETIME No. 031665/01/30/2018
MCLE COMPLIANCE VII-0012699 VALID UNTIL APRIL 14, 2025