Republic of the Philippines)

City of Legazpi
) S.S.

AFFIDAVIT OF LOSS
(SAMPLE ONLY)
I, Herman A. Miranda, of legal age, married, Filipino citizen and a resident of
Barangay 8, Bagumbayan, Legazpi City, after having been duly sworn to in accordance
with law, hereby depose and state that:
1.
I am a member of the Social Security System and was issued an ID
card by the Social Security Sytem Office of Legazpi.
2.
I used to place the said SSS ID card together with other important
documents inside my wallet for safekeeping;
3.
However, sometime last August 2013, my wallet was lost while I was in
Legazpi City.
4.
All my efforts to recover my wallet and all its content including my SSS ID
were in vain.
5.
I am executing this affidavit for the purpose of affirming the truth of the
foregoing statements and for any legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of
September 2013 at Legazpi City, Philippines.

Herman A. Miranda
Affiant
SUBSCRIBED AND SWORN to before me, in Legazpi City, Philippines, this 25th
day of September 2013, by Herman A. Miranda, who has satisfactorily proven his
identity to me through his Department of Interior and Local Government ID No. 5415.

Doc. No. 197

Page No. 41
Book No. 01
Series of 2015.