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REPUBLIC OF THE PHILIPPINES )

CALOOCAN CITY )SS

AFFIDAVIT OF LOSS

I, AIZZA ISIDORA CENTENO III DURANO, of legal age, Filipino, and


resident of 53 Dimasalang Street, Caloocan City, after being duly sworn
in accordance with law, hereby depose and state that:

1. I am a member of the Social Security System and was issued an ID


Card no. 3395.144.047;

2. I used to place the said SSS ID Card together with other important
documents inside my wallet for safekeeping;

3. On October 17, 2018, when I went to a Pawnshop in Bulacan Street,


Caloocan City, I discovered that the SSS ID was irretrievably lost and
can no longer be found despite diligent efforts to locate the same;

4. As such, I am executing this Affidavit to attest to the truth of the


foregoing and in support of my request for the replacement of the said
receipts.

AFFIANT FURTHER SAYETH NAUGHT.

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


November, 2018 in Caloocan City.

AIZZA ISIDORA CENTENO III DURANO


Affiant

SUBSCRIBED AND SWORN to before me this ____________________,


affiant exhibited to me her _______________________ issued at
______________ on__________________.

Doc. No. ______;


Page No. ______;
Book No. ______;
Series of ______.