REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAGAYAN
) S.S.
MUNICIPALITY OF BUGUEY )
x----------------------------------------x

AFFIDAVIT OF LOSS
I, NOLIE J. MOLINA, of legal age, married, Filipino and a resident
of Cabaritan, Buguey, Cagayan, after having been duly sworn to in
accordance with law hereby depose and say:
That I am a holder of a SSS ID issued by the Social Security
System, Tuguegarao, Cagayan;
That said ID was lost and despite diligent efforts to locate its
whereabouts, it is nowhere to be found and is now considered lost and
beyond recovery;
That I am executing this affidavit to attest to the truth of the
foregoing and to request the authorities concerned for the replacement
of the items lost.
IN WITNESS WHEREOF, I have hereunto set my hand this ______
day of _________ 2016 at Buguey, Cagayan.
NOLIE J. MOLINA
Affiant
CTC#______________________
with Barangay Clearance dated
_________________
SUBSCRIBED AND SWORN TO BEFORE ME, this ____ day of
___________ 2016 at Buguey, Cagayan, affiant personally appeared with
his competent evidence of identity.
Witness my hand and notarial seal.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.

ERNANI T. TADILI
NOTARY PUBLIC
Until December 31, 2016
IBP OR No. 946905
PTR OR No. 6485838
Attorneys Roll No. 64233
MCLE Compliance No. V-0013985
Email add: etadili@gmail.com
TCP #. 0947-323-3877