REPUBLIC OF THE PHILIPPINES)

CITY OF PAGADIAN )S.S

AFFIDAVIT OF LOSS

I, xxxxxxxxxxxxxxxxxx, Filipino, of legal age, single/married/widow

and a resident of ______________________, after having been duly sworn
in accordance with law, hereby depose and say:

1. That I am a member of the Social Security System starting year

________ up to the present and consequently, I was issued with the
SSS ID No. ________________;

2. That on ____________, I discovered that said SSS ID card was no

longer in my wallet where I used to place it;

3. That diligent effort to locate the same had proved futile;

4. That said ID card was not confiscated by the authorities or used in

violation of the law;

5. That I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of said Identification
card from SSS.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_________________ at _________________, Philippines.

xxxxxxxxxxxxxxxxxxxx
affiant

SUBCRIBED AND SWORN TO before me

this ___________________ in ____________, Philippines, affiant exhibiting
to me his valid proof of identification.