REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS ) S.S

X---------------------------------------------X

AFFIDAVIT OF LOSS

I, HELI JOHN A. BERMUDEZ, of legal age, married, Filipino, a

resident of Brgy. Cabugao Oeste, Panay, Capiz after having been duly
sworn to in accordance with law, do hereby depose and state;

1. I am the holder of a SSS ID CARD issued by Social Security System

(SSS);

2. That I kept the said SSS ID CARD in our drawer at home together
with my other important documents;

3. That recently, when I tried to look for the same, I noticed that my
SSS ID CARD was not anymore in my possession.

4. Despite my diligent effort to recover or locate the same, I was not

able to find my SSS ID CARD such that I consider my SSS ID CARD
lost.

5. I am executing this affidavit to attest to the truth of the foregoing

facts and for the Social Security System (SSS) to issue me a new SSS
ID CARD in lieu of the lost one.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this

______________ at ____________________.

HELI JOHN A. BERMUDEZ

Affiant
Drivers License No. F04-97-035154
(Valid Until 2017-10-09)

SUBCRIBED AND SWORN to before me this ________________ at

___________________, affiant exhibiting to me his Competent Evidence of
Identity.