REPUBLIC OF THE PHILIPPINES )

Province of Misamis Occidental) S.S.

City of Ozamiz)
x---------------------------------------x

AFFIDAVIT OF LOSS

I, XXXXXXX, Filipino, of legal age, single and a resident of Archbishop

Residence, Chancery Office, Catadman, Ozamiz City, after having
been duly sworn in accordance with law, hereby depose and state:

1. That I am a holder of SSS ID No. XXXXX issued by the Social

Security System, Republic of the Philippines;

2. That on April 6, 2018 at around 3 o’clock in the afternoon, whle

I was in Tangub City , I lost my wallet which I usually place in my
left back pocket;

3. That I now believe that they are now lost beyond recovery
because despite diligent search and efforts to locate the said
wallet with my SSS ID Card and other pertinent documents, I
could not find them;

4. As such, I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support my application for the
issuance of a new SSS ID Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 9th day of

April at Ozamiz City, Philippines.

_________________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and

for City of Ozamiz and the Municipalities of Clarin and Tudela in the
province of Misamis Occidental this 9th day of April, 2018. Affiant
personally came and appeared with Senior Citizen’s Identification Card
issued by the Local Government of Ozamiz City-Social Welfare and
Development Office issued on April 7, 2018 at Ozamiz City bearing
his photograph and signature, known to me as the same person who
personally signed the foregoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said
instrument.

ATTY. LHEM JAPOS NAVAL

Notary Public for the City of Ozamiz
and the Municipalities of Clarin and
Tudela until December 31, 2019
Roll No. 67711
IBP Lifetime Roll No. 017073
PTR No. 3035024A-01/04/2018
TIN 923-610-646
MCLE Compliance Cert. No. VI-0004857

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