Republic of the Philippines)

Tarlac City, Tarlac ) S.S.

AFFIDAVIT OF LOSS

I, Teddy R. Salangsang, of legal age, married, Filipino citizen, with residence address at SS
Village Barangay Binauganan ,under oath, depose and state:

(1) I, loss my SSS Identification card with card number 03-8339550-0

(2) On January 10, 2009 I lost my wallet when I rode a bus going to Manila during which the said
above ID is one of the content of the said wallet.

(3) Diligent search of said Identification card and wallet with the bus company proved futile and
unavailing.

(4) I am executing this affidavit to comply with the requirements of Social Security System for the
re-issue of said Identification Card.

Affiant further sayeth naught.

TEDDY RODRIGUEZ SALANGSANG

SUBSCRIBED AND SWORN to before me this day of February 17, 2009 in Tarlac City, Tarlac
affiant exhibiting to his Community Tax Certificate No. __________ issued on _____________ at
____________.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of