AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES)

_____________________________ ) S.S.

I, TROY P. TE-ELAN, Filipino, of legal age, and a resident of #768,

Chackong, Bontoc Ili, Bontoc, Mountain Province, after having been
duly sworn in accordance with law, hereby depose and say:

1. That I am a holder of a Social Security System (SSS)

identification card issued in 2016;

2. That I used to put said identification card in my purse;

3. That sometime on May 25, 2018, I discovered that my purse,

along with my SSS ID card, got stolen at the dressing room of
Baguio General Hospital;

4. That despite diligent search and efforts to locate said ID, I

could not find it;

5. That I am executing this affidavit to attest to the truth of the

foregoing facts and to request for a replacement of said SSS ID
card from Social Security System

IN WITNESS WHEREOF, I have hereunto set my hand this _____

day of _______________, 2018 at _________________________.

TROY P. TE-ELAN

SUBSCRIBED AND SWORN to before me, this ____ day of

______________, 20___ in ______________________, with affiant
exhibiting his __________________ , Issued on ______________________
at _________________________.

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20_______.