Affidavit of Loss
Affidavit of Loss
Affidavit of Loss
City of Cabuyao)
Province of Laguna) S.S.
AFFIDAVIT OF LOSS
I, Royce Dimailig Villalobos, Filipino, of legal age, single and residing at Block 17 Lot
10 Hongkong Village Barangay Banay-Banay, Cabuyao City, Laguna, after having
been sworn to in accordance with law hereby depose and state:
That I am a holder of SSS Card bearing SSS Number CRN 0033-3478983-2 issued
by the Social Security System;
I lost the said ID cards while I was in the Emergency Room of Our Lady of Mary
Mediatrix Hospital in Lipa City, Batangas.
That the same could not be found despite diligent efforts to locate it;
That I am executing this affidavit to certify the loss of the above-mentioned ID for
the purpose of securing its replacement from the Social Security Systems and
Maxicare Healthcare Corporation.
______________________________
SIGNATURE OVER PRINTED NAME
Affiant
NOTARY PUBLIC
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20__