REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.

x--------------------------------------------------x

AFFIDAVIT OF LOSS

I, EVELYN GEMINA, of legal age, Filipino, married, and a resident

of Brgy. Bulad, Guimbal, Iloilo, Philippines, after having been duly sworn
to in accordance with law hereby voluntarily depose and say that:

1. Last 2013, I applied for a Maternity Benefit before the Social Security
System (SSS) Iloilo Branch;

2. By virtue of such application, I was required to accomplish the

Maternity Notification Form;

3. However, sometime last month, I discovered that the said Maternity

Notification Form is no longer in the place where I usually keep the
same;

4. Despite my diligent search and efforts, I cannot find the said Maternity
Notification Form;

5. Henceforth, I consider it as lost and beyond recovery;

6. I am executing this affidavit to the truthfulness of the foregoing. This

Affidavit attests for the purpose of allowing me to apply for the afore-
mentioned benefit in the SSS.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________ in the City of Iloilo, Philippines.

EVELYN GEMINA
Affiant
UMID ID No. CRN-0111-0056331-0

The affiant, whose name and personal circumstances are stated

above, personally appeared before me this _______ in the City of Iloilo,
Philippines, presented the foregoing affidavit, signed the same in my
presence and affirmed under oath to the correctness of the contents or
allegations of the same.
The affiant was identified by competent evidence of identity
appearing below his name.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2021.