Republic of the Philippines

)
City/Municipality of ___________)
Province of __________________) S.S.

AFFIDAVIT OF LOSS
I, _____________________________________________, Filipino, of legal age,
married/single and residing at __________________________________________________,
after having been sworn to in accordance with law hereby depose and state:
That
I
am
a
holder
of
SS
Card
bearing
SS
________________________/Common
Reference
Number
_________________________ issued by the Social Security System;

Number
(CRN)

That last _______________________, I lost the said ID while

__________________________________________________________________
__________________________________________________________________
_________;
That the same could not be found despite diligent efforts to locate it;
That I am executing this affidavit to certify the loss of the above-mentioned ID for
the purpose of securing its replacement from the SSS.
AFFIANT FURTHER SAYETH NAUGHT.

SIGNATURE OVER PRINTED NAME

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ______________, 20___ in

___________________ City, with affiant exhibiting his/her CTC No. ____________________,
issued on ______________________ at _________________________.

NOTARY PUBLIC
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20____.