Republic of the Philippines )

) S.S.

AFFIDAVIT OF LOSS
I, ___________, of legal age, Filipino citizen and with residence and
postal address at ___________, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. I am the owner and possessor of UMID bearing ID No.

___________ issued by the Social Security System;

2. On ___________, the aforesaid ID was lost during checkpoint in

___________and that despite of all efforts possible that I exerted
to locate the same, I could not find it thus considered it lost beyond
recovery;

3. Said UMID was not confiscated by any officer of the law by reason
of any violation of law, ordinance, or any rules and regulations; and

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

facts, to support my application for a new UMID in lieu of the lost
one, to inform the proper authorities concerned and for whatever
legal purpose this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand and affix my

signature this ____ day of ________________ at
_____________________.

___________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of

______________ in ___________________, affiant exhibited to me her
Government Issued ID which is a ___________ containing her photograph
and signature.

Doc. No. ___;

Page No. ___; NOTARY PUBLIC
Book No. ___;
Series of 2022.