AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________) S.S.

I, Alex Dubria Vista, Filipino, of legal age, married and residing at #020 Aloe Vera St.,
Payatas A, Quezon City, after being duly sworn in accordance with law do hereby depose and
state:

1. THAT I have lost my Social Security System Identification Card sometime around
August of 2015;
2. THAT I exerted due diligence and persistent efforts in locating the aforesaid SSS ID
but to no avail;
3. THAT I consider the same lost and can no longer be found;
4. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to
use the same for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT

IN WITNESS WHEREOF, I hereunto affix my signature on ________________ at

_____________, Philippines.

Alex Dubria Vista

Affiant

SUBSCRIBED AND SWORN to before me this ____________________ at

______________, Philippines.

Notary Public

Doc No. ___

Page No. ___
Book No. ___
Series of 2018.