REPUBLIC OF THE PHILIPPINES)

PROVINCE OF EASTERN SAMAR) S.S.

MUNICIPALITY OF BALANGIGA
x----------------------------x

AFFIDAVIT OF LOSS

I, MANUEL L. MORTOLA, JR., of legal age, Filipino, and a resident of Brgy. Gigoso,
Giporlos, Eastern Samar, after having been duly sworn to in accordance with law, depose and
state THAT:

1. I am a holder of a Social Security System (SSS) Identification Card issued by the Office of the
Social Security System (SSS), Metro Manila.

2. The said SSS Identification Card while in my possession was lost during the onslaught of
SUPERTYPHOON YOLANDA last December 8, 2013 and could no longer be located in spite of
diligent efforts to locate the same;

3. Said Identification Card was not confiscated by any officer of the law by reason of any violation
of any law, ordinance, presidential decree or rules and regulation of the said Commission;

4. I shall assume responsibility or liability if in any event I will use these documents for
whatever illicit transactions;

5. I am executing this affidavit to attest to the veracity of my statements and to support my request
for the issuance of my lost SSS Identification Card.

IN WITNESS WHEREOF, I have hereunto set my hand this February 5, 2017 in

Balangiga, E. Samar, Philippines.

MANUEL L. MORTOLA, JR.,

Affiant

SUBCRIBED AND SWORN TO before me this in February 5, 2017, in Balangiga, E.

Samar, Philippines, affiant exhibiting to me his TIN CARD with no. 274-955-268 issued on May
14, 2009.

ATTY. MEL JUN A. DIASANTA

Notary Public
Commission Expires Dec. 31, 2017
Doc. No. _____; Commission No. 0019-15
Roll of Attorney’s No. 62978
Page No. _____; PTR. No. 9302944/01-17-2017/Balangiga, E. Samar
IBP No. 1067374/01-25-2017/Leyte Chapter
Book No. V; P. Duran St., Brgy. 05, Balangiga, E. Samar
Series of 2017.