Republic of the Philippines )

S. S.
______________________

AFFIDAVIT OF LOSS

I, _______________________________, Filipino, of legal age, married/single and resident of

______________________________________________________ after having been sworn in
accordance with law hereby depose and say:
That I am a holder of SS digitized ID No. ____________ issued by the Social Security
System;
That

last

____________________

lost

the

said

ID

while

_____________________________________________.
That the same could not be found despite diligent efforts to locate it;
That I am executing this affidavit to certify the loss of the above document for the purpose of
securing its replacement from the SSS.
AFFIANT FURTHER SAYETH NAUGHT.
__________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________________.

Affiant

exhibited to me her Taxpayers ID No. _________________, issued on ______________ at

____________.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2013

NOTARY PUBLIC