AFFIDAVIT OF LOSS

I, ____________________________, of legal age, Filipino, single and resident of

_______________________________________, after being sworn according to law, hereby depose and
state that:

1. I am a member of the Social Security System and was issued an ID Card with an
SSS No ________________________.

2. On October 2, 2017, Monday, I lost the above Identification Card together with
some important documents under unknown circumstances and that the said
document was nowhere to be located.

3. Despite diligent efforts exerted, I could no longer locate, find or recover the said
Identification Card and to the best of my knowledge, the same is truly lost.

4. The said Identification Card has not been confiscated by any officer of the law or
the issuing office or agency due to the violation of any law, statute, order, rule or
regulation.

5. I am executing this Affidavit to attest to the truth of the foregoing statements and
for any legal purposes my serve.

AFFIANT FURTHER SAYETH NAUGHT:

IN WITNESS WHEREOF, I have hereunto set my hands this October 03, 2017 at Cebu
City, Philippines

________________________________ __
Affiant

SUBSCRIBED AND SWORN to before me this ____________, affiant exhibited to me his TIN
______________________________.

Doc. No. ____

Page No. ____
Book No. ____
Series No. 2017