Republic of the Philippines)

Camiling, Tarlac ) S.S.

AFFIDAVIT OF LOSS
I, _________________________, of legal age, Filipino citizen,
single/married/widow/widower, and a resident of
_____________________________, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and state THAT:

1. I am a holder of a Social Security System ID Card (SSS ID

Card) issued by the Social Security System of the Philippines;

2. Lately, when was I looking for the said ID, I discovered that the
same was missing;

3. After diligent effort to locate the said SSS ID Card the same
proved futile, hence, I now consider the same as lost and beyond
recovery;

4. I am executing this affidavit to confirm and affirm to the

truthfulness of the above statements and request the Social
Security System of the Philippines to issue me another SSS ID
Card in lieu of the lost one.

IN WITNESS WHEREOF, I hereunto affixed my signature this ___

day of _________, 2019, at Camiling, Tarlac, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

indicated above. Affiant exhibited to me his ___________________.