Republic of the Philippines)

City of Batangas )
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AFFIDAVIT OF LOSS

I, Howard O. Untalan, 32, Filipino, single and a resident of Lot1 Block17, Magnusville subd.
Pallocan West, Batangas City, Philippines, after having been duly sworn in accordance with law,
hereby deposes and state:

1. That I am a holder of Social Security System(SSS) E-1 Form issued by Social

Security System with SSS NO. 04-1612808-4, Philhealth ID with Number
090501115184, BIR ID with Number 307-075-655 issued by Bureau of Internal
Revenue and Pagibig MID ID No. 1210-3161-2856;
2. That Sometime in July 5, 2017, I lost my wallet with under the following
circumstances: Sometime in July 5, 2017, after arriving from office, I was just
surprised to have known that my wallet containing all my important
IDENTIFICATION CARDS mentioned above was already missing as it might have
been forcibly taken out from my bag which was then slashed on its upper right side
corner;
3. That despite diligent efforts exerted, I could no longer locate, find or recover the my
wallet containing my important identification cards, and to the best of my knowledge,
the same is truly lost;
4. That said wallet with my identification cards (Social Security System(SSS) E-1 Form
issued by Social Security System with SSS NO. 04-1612808-4, Philhealth ID with
Number 090501115184, BIR ID with Number 307-075-655 issued by Bureau of
Internal Revenue, Pagibig MID ID No. 1210-3161-2856) has not been confiscated by
any officer of the law or the issuing office or agency due to the violation of any law,
statute, order, rule or regulation;
5. That in the event that the lost wallet with my identification cards (Social Security
System(SSS) E-1 Form issued by Social Security System with SSS NO. 04-1612808-4,
Philhealth ID with Number 090501115184, BIR ID with Number 307-075-655 issued
by Bureau of Internal Revenue, Pagibig MID ID No. 1210-3161-2856) should
hereafter be found or located, I undertake to forward or surrender the same to its
issuing government agency; and
6. That I am executing this affidavit to attest to the truth of the foregoing statement and
to request for the issuance of a new identification cards (Social Security System(SSS)
E-1 Form issued by Social Security System with SSS NO. 04-1612808-4, Philhealth
ID with Number 090501115184, BIR ID with Number 307-075-655 issued by Bureau
of Internal Revenue, Pagibig MID ID No. 1210-3161-2856) in lieu of the one which
was lost.
 AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ______ 2017
at Batangas City, Philippines.

Howard O. Untalan
AFFIANT

SUBSCRIBED AND SWORN to before me this ______ day of _______ 2017, affiant
exhibited to me his competent evidence of identity by way of ________________________
issued at ___________________________ on ________________________.

NOTARY PUBLIC

Doc No. __________ ;

Page No. __________;
Book No. __________;
Series of 20_________.