Republic of the Philippines )

Bacolod City, Negros Occidental ) S.S.

X--------------------------------------------X

AFFIDAVIT OF LOSS

KNOW ALL MEN BY THESE PRESENTS:

I, __________________, of legal age, Filipino, married, with resident address at

Lot _________________Negros Occidental, after having been sworn in accordance
with law, hereby deposes and states:

That I am the holder/owner/ or possessor of _________ Card with #________

That sometime November, I noticed that my wallet which contains my SSS UMID
Card could no longer be found and that despite of diligent search of said wallet and ID
among our personal effects, the same proved futile, that I now believe that it is lost
beyond recovery.

That I am executing this affidavit to attest to the truthfulness of the foregoing, and
for purposes of applying for replacement of my SSS UMID ID.

Signed this ______________________, at the City of Bacolod, Philippines.

_________________________
Affiant
(Signature over Printed Name)
ID
Issued on
Issued at

SUBSCRIBED and SWORN TO before me on the date and at the place indicated
below. The affiant exhibited to me her _____________________ as competent
evidence of identity as indicated above.

Signed this ______________at ________________, ______________________,

Philippines.

WITNESS MY HAND AND SEAL.

Notary Public

Doc. No. ____

Page No.____
Book No.____
Series of ____