REPUBLIC OF THE PHILIPPINES )

______________________ ) S.S.
________________________ )
X-------------------------X

AFFIDAVIT OF LOSS

I, ZZZZZZ , of legal age, Filipino, married, and a resident

of__________________________, Philippines, after having been duly sworn in
accordance with law, hereby depose and state:

1. That I a member of the Social Security System (SSS) and I have been
consistently paying my contributions to the said agency;

2. That I have lost my SSS payment contribution receipts from January 2004
to December 2015 due to the constant transfer of business and personal
documents;

3. That I exerted efforts to retrieve the said receipts through checking my

belongings, but it proved to be fruitless;

4. That I lost the through in good faith and with the exercise of diligence of a
reasonable and prudent person exercising care over her things and
circumstances;

5. That I am executing this affidavit in order to attest to the veracity of the

foregoing facts and for whatever legal purpose this may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

at Maramag, Bukidnon, Philippines.

ZZZZZZ
Affiant

SUBSCRIBED AND SWORN to before me, this _______________ by affiant who

is personally known to me. I HEREBY CERTIFY THAT HE UNDERSTOOD THE CONTENTS
OF THIS AFFIDAVIT AND THAT THE SAME IS TRUE AND CORRECT ACCORDING TO HIS
OWN KNOWLEDGE AND BASED ON AUTHENTIC RECORDS.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2017.