Republic of the Philippines)

Province of Albay
) Sc.
Municipality of Daraga
)

AFFIDAVIT OF LOSS
I, ___________________, of legal age, married, Filipino citizen and a
resident of San Roque, Daraga, Albay, after being sworn to in accordance with
law, do hereby depose and state:

That I a member of Social Security System and I a holder of SSS card

bearing SSS number 05-05545454545;

That sometime last week I found out that said SSS card was no longer in
my wallet.

That despite diligent search and efforts to locate the said SSS card, I
could not find the same such that I now believe that it is now lost beyond
recovery;

That I am executing this Affidavit to attest to the truth of the foregoing

and to support the application for the issuance of new one in lieu of the
one that was lost.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this _____st day of
January 2015, at Daraga, Albay, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____ day of January 2015,

at Daraga, Albay, affiant exhibited to me her _____________________ issued by
____________________ valid until _____________________.

Doc. No._____
Page No._____
Book No._____
Series of 2015.