Republic of the Philippines)

City of Legazpi
) s.s.
x-------------------------------------------x

AFFIDAVIT OF LOSS
I, MYLENE GO- ABRINA, of legal age, Filipino citizen and with
residence and postal address at Door C, Block 21, Lot 7, Our Ladys Village,
Brgy. Bitano, Legazpi City, after having been duly sworn in accordance with
law do hereby depose and state:
1. That I am the Operation Manager of ONE HALF STAFFING
SOLUTIONS registered in the Social Security System.
2. That I am in charge of keeping the official receipts of the payment
of SSS contributions.
3. However, due to some circumstances, I lost some receipts indicated
below:

SBR NUMBER
E0103070050034
2
E0103070050034
1
E0103070050034
0
E0103070050033
9
E0103070050032
4
E0103070050032
3

APPLICABLE
PERID
June 2013

AMOUNT
PAID
P36,045.00

DATE OF
PAYMENT
August 5, 2014

July 2013

P36,045.00

August 5, 2014

August 2013

P39,225.00

August 5, 2014

September 2013

P19,625.00

August 5, 2014

September 2013

P31,429.00

October 15, 2014

November 2013

P54, 496.00

October 15, 2014

4. That I am executing this affidavit to attest the truth of the foregoing

statements and for the purpose of complying with the requirements
of Social Security System.
IN WITNESS WHEREOF, I have hereunto
________________________ at Legazpi City, Philippines.

set

my

hand

this

MYLENE GO-ABRINA
Affiant
ID No. ____________
Issued By: _________

SUBSCRIBED AND SWORN to before me this __________________at Legazpi City,

Philippines. Affiant exhibited to me her Identification Card indicated below her
name bearing her photograph and genuine signature as competent proof of
identify pursuant to the 2004 Rules on Notarial Practice.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2016.