REPUBLIC OF THE PHILIPPINES )

CITY OF MANDAUE ) S.c.

AFFIDAVIT OF LOSS
I, MILAGROS A. SUSCANO, of legal age, single, Filipino and a
resident of Block , Lot !, "#ase $A, %illa Le&son, Baca&an, 'ala()an
Ce)*, after )eing s+orn to in accordance +it# la+, depose and sa& t#at,
-. I +as pre.io*sl& iss*ed an SSS I/ +it# n*()er 012$33!1!$2$4
$. I *sed to keep t#e a)o.e2(entioned e.idence of identit& in (&
)ag4
5. A)o*t a co*ple of (ont#s ago, +#ile I +as on (& +a& to (&
+orkplace, I accidentall& left (& )ag or (isplaced it4
. I tried all efforts to locate t#e (isplaced )ag toget#er +it# its
contents )*t I +as not a)le to find it4
!. '#e SSS I/ is no+ )e&ond reco.er&4 and
1. I a( e6ec*ting t#is s+orn state(ent, as re7*ired, to ena)le (e
to o)tain a replace(ent for t#e said lost doc*(ent.
IN 8I'N9SS 8:9R9OF, I #a.e #ere*nto set (& #and t#is ;;; da&
of Ma& $0-, in t#e Cit& of Manda*e, "#ilippines.
<9N9%I9 M. 'AN<A=
Affiant
JURAT
SUBSCRIB9/ and s+orn to )efore (e, t#is ;;; da& of Ma& $0-, in
t#e Cit& of Manda*e )& ;;;;;;;;;;;;;;;;;;;;;;;; +it# t#e follo+ing
co(petent e.idence of identit&,
9.idence of Identit& I/ N*()er Iss*ed /ate Iss*ed At
/oc. No. ;;;4
"age No. ;;;4
Book No. ;;;4
Page 1 of 2
Series of $0-.
Page 2 of 2