Republic of the Philippines

)
City of Iloilo
) S.S.
x--------------------------------x
AFFIDAVIT OF LOSS
I, MARIA GLO TAGUDINAY JIMENA, Filipino, married and
resident of Pavia, Iloilo, after having been sworn to in accordance with
law, hereby depose and state:
1. That I am a bona fide member of the Social Security System;
2. That I have been religiously paying my SSS contribution since
February 2013 up to the present;
3. That I was in possession of the receipts for said payment;
4. That however when the need for said receipts arose, I
discovered that my receipts for February 2013; January to March 2014;
April to June 2014; and July to September 2014 could not be found;
5. That despite exerting diligent and earnest efforts to locate said
receipts, the same could no longer be found and is beyond recovery;
and
6. That I execute this affidavit to attest to the truth of the
foregoing facts
and for whatever purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 29th
day of December 2014 at Iloilo City, Philippines.

MARIA GLO T. JIMENA

SUBSCRIBED AND SWORN to before me, this 29th day of

December 2014 at Iloilo City, Philippines, affiant acknowledged that
she has fully understood the contents of her affidavit.

Doc. No.: ___;

Page No.: ___;
Book No.: ___;
Series of 2014.