REPUBLIC OF THE PHILIPPINES )

CITY OF SAN FERNANDO, [P] ) S.S.

AFFIDAVIT OF LOSS

I, JENESIS PANTIG LAUS, of legal age, Filipino, single, and

a resident of 436 St. Mathew, Sto. Niño, Lagundi Mexico,
Pampanga, subscribing under oath, depose and state that —

1. I am a holder of a Unified Multi-Purpose

Identification Card (UMID) issued by the Social Security System;

2. The said identification card got lost or misplaced for

2 weeks now and I can no longer find the same despite diligent
efforts. Hence, I now consider it beyond recovery;

3. The said identification card has not been confiscated

by any officer of the law or the issuing office or agency due to
the violation of any law, statute, order, rule or regulation;

4. Despite diligent efforts exerted, I could no longer

locate, find or recover the said identification card and to the
best of my knowledge the same is truly lost;

5. I am executing this Affidavit of Loss to attest to the

truth of the foregoing and to support the application for the
issuance of new one in lieu if the one which was lost.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this October 28, 2020 at City of San Fernando, Pampanga.

JENESIS PANTIG LAUS

Affiant
ID No._____________

SUBSCRIBED AND SWORN before me this October 28, 2020 at City

of San Fernando, Pampanga by affiant, personally known to me, who
is the same person who personally signed before me the foregoing
affidavit and acknowledged that she executed the same.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2020.