Republic of the Philippines ) City/Municipality of ___________) Province of __________________) S.S. AFFIDAVIT OF LOSS I, _____________________________________________, Filipino, of legal age, married/single and residing at __________________________________________________, after having been sworn to in accordance with law hereby depose and state: That I am a holder of SS Card bearing SS ________________________/Common Reference Number _________________________ issued by the Social Security System; Number (CRN) That last _______________________, I lost the said ID while __________________________________________________________________ __________________________________________________________________ _________; That the same could not be found despite diligent efforts to locate it; That I am executing this affidavit to certify the loss of the above-mentioned ID for the purpose of securing its replacement from the SSS. AFFIANT FURTHER SAYETH NAUGHT. SIGNATURE OVER PRINTED NAME Affiant SUBSCRIBED AND SWORN to before me this ____ day of ______________, 20___ in ___________________ City, with affiant exhibiting his/her CTC No. ____________________, issued on ______________________ at _________________________. NOTARY PUBLIC Doc. No. : ________; Page No. : ________; Book No. : ________; Series of 20____.