Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT OF LOSS

I, CLAUDINE L. FLORES, Filipino, married, of legal age, resident of Brgy. Santiago

Malvar, Batangas, Philippines, after having been sworn by law hereby depose and state
that:

1. I am the owner of a UMID ID issued by the Social Security System;

2. Sometime around June 22, 2024, on the NAIA Road in Pasay, Metro Manila around
10:00 pm, I lost the above UMID ID under the following circumstances;

3. despite diligent efforts exerted, I could not locate or recover the said UMID ID, and to
the best of my knowledge, the same is truly lost;

4. The said UMID ID has not been confiscated by any officer of the law or the issuing
agency or office due to the violation of any law, statute, order, rule, or regulation;

5. If the lost UMID ID should hereafter be found or located, I undertake to forward or

surrender the same to the company where I worked for appropriate disposal;

6. I am executing this affidavit to attest to the truth of the foregoing and to request the
issuance of a new UMID ID to replace the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this 08th of July, 2024, in Malvar,
Batangas, Philippines.

CLAUDINE L. FLORES
Affiant
Issued ID: Postal ID
ID No. PRN F25220655573

SUBSCRIBED AND SWORN to before me on this 08th day of July 2024, in Malvar,
Batangas Philippines.

Doc. No. ;
Page No. ;
Book No.
; Series of 2024.