REPUBLIC OF THE PHILIPPINES )

CITY OF ORMOC ) S.S.

AFFIDAVIT OF LOSS

I, RUFINO T. EAMIGUEL, of legal age, Filipino, and residing at Brgy.

Alegria Ormoc City, after having been duly sworn to in accordance with law
depose and say:

1. That I am a member of Social Security System (SSS) Ormoc City Branch;

2. That my membership at the Social Security System (SSS) id of self-
employed person;
3. That I filled up an SSS RS-1 form with SSS Number 06-3595910-2 for
self-employed members;
4. That the RS-1 form that I have filled up was lost and misplaced and
could not be found anymore notwithstanding my diligent efforts to
locate the same;
5. That I am voluntarily executing this affidavit of loss to attest the
foregoing facts to be true and correct and for whatever legal purpose
this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of

October 2017 in the City of Ormoc.

RUFINO T. EAMIGUEL
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 10th day of October 2017 in

the City of Ormoc.