AFFIDAVIT OF LOSS

I, JONALISA ASIGNAR, Filipino, of legal age, married and a resident of 183-B

San Jose dela Montaña St., Mabolo, Cebu City after having been duly sworn in
accordance with law, hereby depose and say:

1. That I am a bona fide member of the Social Security System;

2. That in that capacity, I was issued a member’s Identification Card (ID) # 06-
1896420-8by the Social Security System;
3. That I placed the said ID inside a safe cabinet in my house together with
some important papers as file;
3. That recently, I discovered the loss of the said ID;
4. That I have exerted diligent effort to locate said ID, but all my efforts were in
vain;
5. That their affidavit is executed to establish the foregoing facts and to support
my application for the issuance of a new ID in lien of the lost one.

IN WITNESS WHEREOF, I hereby signed this affidavit, this 20th day of January,
2004 at the City of Cebu, Philippines.

JONALISA D. ASIGNAR
Affiant

SUBSCRIBED AND SWORN to before me, this____day of January,

2004 in the City of Cebu, Philippines. Affiant exhibited to her CTC #________
_____ issued in__________________on_____________.

Doc. No.____
Page No. ____
Book No. ____
Series of 2004