REPUBLIC OF THE PHILIPPINES )

PROVINCE OF )S.S.
CITY OF )

AFFIDAVIT OF LOSS

I, ___________________, Filipino, of legal age, and a resident of

_________________, after having been duly sworn in accordance with law, hereby
depose and say:

1. That I am a member of the Social Security System (SSS) with SSS

number _______________;

2. That unfortunately, when I was looking for my RS-1 Form for my

retirement application but I could no longer find it in any off my
belongings;

3. That diligent efforts have been made to recover the said RS-1 Form but
to no avail, thus I am considering it lost forever;

4. That I am executing this affidavit to attest to the foregoing facts and for
legal intents and purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day of

__________ at _______________.

____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ____________,

affiant exhibited his/her _________ ID with no. _________________.

Doc. no.:
Page no.:
Book no.:
Series of 20____