REPUBLIC OF THE PHILIPPINES )

)SS.
X-----------------------------------------X

AFFIDAVIT OF LOSS

I, GRACE F. SARSUA, Filipino, of legal age, single, and a resident of

B40 L42 Zontaville PH3A, Brgy. San Isidro, Antipolo City, after having
duly sworn to in accordance with law, hereby depose and say that:
1. I am a holder of a Social Security System (SSS) ID issued by
SSS Main in Quezon City;
2. I lost said ID card sometime in January 2015 and I could not
remember exactly where I placed/left my wallet containing the said I.D
Card and it is now considered lost for all legal purposes;
3. That all efforts have already been exerted to locate the same but
only proved futile;
4. I am executing this affidavit to attest to the truth of all the
foregoing facts and for whatever lawful purposes this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 15 th day
of July, 2015 in the _____________, Philippines.

GRACE F. SARSUA
Affiant
SUBSCRIBED AND SWORN to before me this 15th day of July
2015, affiant exhibited to me her Voters ID with No. 5802-0214AJ2184GFS20001-7 issued by Commission on Elections, Antipolo City.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2015.

NOTARY PUBLIC