REPUBLIC OF THE PHILIPPINES)

CITY OF ANTIPOLO ) S.S.

AFFIDAVIT OF LOSS
____________________________________________________________

I, ________________________________, of legal age, single/married and

resident of _________________________, after having duly sworn to in accordance
with law, hereby depose and state, that:

1. I am a holder of RS-5 contributions payment of _____to ____issued by Social

Security System (SSS) which I kept for safekeeping; (more than one-month
payment e.g. July 2014 to November 2014)

2. I am a holder of RS-5 contributions payment of ____________ issued by Social

Security System (SSS) which I kept for safekeeping; (1month payment only
e.g. January 2014 only)

3. Unfortunately, on __________, my RS-5 contributions of ____________payment

was lost or misplaced and it must have been dropped off or slip off from me;

4. Diligent search and inquiry to locate said RS-5 contributions payment of

______________ proved of no avail, hence, considered lost;

5. I am therefore executing this affidavit of loss to attest to the truth of the foregoing
facts and for legal purpose this may serve;
6.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my hands this ____ day of

__________ 2019 in Antipolo City.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of __________ 2019 in

Antipolo City. Affiant exhibiting to me his/her ID no:__________________;

Doc No: ____;

Page No: ____;
Book No: ____;
Series of 2019