Republic of the Philippines )

Malolos City, Bulacan ) S.S.

AFFIDAVIT OF LOSS

I, MIRASOL G. LUCIAJA, of legal age, married, Filipino, and

presently residing at Block 8, Lot 28, Camella Avisea Brgy. Bignay,
Valenzuela City after being duly sworn to in accordance with law depose
and state, that:

1. I am a holder of a Digitized SSS ID No. 33-6969400-2 issued to me

by SSS East Avenue, Quezon City;

2. Sometimes in November 2012, I noticed that the subject SSS I.D. was
left at the counter of SM North Edsa, Quezon City;

3. I exerted diligent effort to locate the same but all efforts are all in
vain; and

4. I executed this affidavit to attest the truth of the foregoing set of facts
and to inform the authorities for all legal intents and purposes.

MIRASOL G. LUCIAJA
Affiant

SUBSCRIBE AND SWORN to before me this __th day of _____ 2016

at Malolos City. Affiant exhibited to me her Passport ID with number
EC6896419 that she is the same person who personally signed the
foregoing affidavit before me and acknowledged that she executed the
same.

Doc. No. 330;

Page No. 67;
Book No. VI;
Series of 2016.