Republic of the Philippines )

Camiling, Tarlac
) S.S.

AFFIDAVIT OF LOSS
I, AURELIA A. AGUSTIN, of legal age, Filipino citizen, and a resident of
Barangay Manaquem, Camiling, Tarlac, Philippines, after having been duly sworn
to in accordance with law, do hereby depose and state THAT:
1. I am the mother of the late NELLY ASUNSCION AGUSTIN (Nelly, for
brevity), who, during her lifetime, is a member of the Social Security
System (SSS) of the Philippines;
2. Nelly died on May 7, 2006 at the age of 45. As a member of the SSS,
she is entitled for Funeral/Burial benefit;
3. Lately, when I went to the SSS Camiling, Tarlac to apply/file for the
funeral/burial benefit of my late daughter, I was required to submit
copies of the SBR receipt of payment of contributions of Nelly;
4. After going over the personal effects and documents of Nelly, I
discovered that the SBR receipts with Number 243205 and 984286
were missing. Thus, I searched all the possible drawers and envelopes
where the said receipts might have been transferred but I did not find
the same;
5. Diligent efforts exerted to locate the said SBR contribution receipts
proved futile; hence, I now consider them as lost and beyond
recovery;
6. I am executing this affidavit to attest to the truth of the foregoing
statements and for all legal intents and purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 23 rd day of
November, 2016 at Camiling, Tarlac, Philippines.
AURELIA A. AGUSTIN
Affiant
SUBSCRIBED AND SWORN to before me on the date and place
indicated above. Affiant presented before me her Senior Citizen ID Card with
Control Number 7408 issued by the OSCA, Camiling, Tarlac.

Doc. No.________;
Page No.________;
Book No.________;
Series of 2016.