Republic of the Philippines )

Province of Tarlac ) S. S.

AFFIDAVIT OF LOSS

That I, ____________________________, of legal age, Filipino,

single and a resident of __________________________after having been
duly sworn to in accordance with law do hereby depose and say:

That I am a holder/possessor of an Unified Multi-Purpose ID (UMID)

with _________________________ issued by the Social Security System
(SSS);

That on ____________________, I lost my wallet which contained my

UMID when I was on my way home, probably left in the tricycle;

That I exerted diligent efforts to locate the same but it proved futile;

That it was not confiscated for any violation of the law;

That this affidavit is executed freely and voluntarily without any fraud,
duress, force and/or intimidation whatsoever but to confirm and affirm the
aforementioned facts as the basis of any legal intent and purpose it may
serve;

IN WITNESS WHEREOF, I have here unto set my hand this

_______________ day of ____________________ in the
____________________, Philippines.

___________________________________
Affiant

SUBSCRIBED AND SWORN to before me on the date and place first

above written.

Doc. No.___
Page No.___
Book No. ___
Series of 2019.