Republic of the Philippines )

Province of La Union )S.S.

Municipality of Naguilian )
x----------------- --x

AFFIDAVIT OF LOSS
I, BERLINDA C. GAPASIN, Filipino, of legal age, widow, and a resident
of Brgy. Bancagan, Naguilian, Naguilian, La Union, Philippines, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I am a bonafide member of Social Security System (SSS) and I

was issued a corresponding SSS ID in their branch office in San
Fernando, La Union;

2. That I kept such SSS ID in my wallet for safekeeping;

3. That sometime on May 30, 2016, at around 12:00 – 2:00 pm, while I
was on board a bus going to Manila, my SSS ID must have been
dropped from my wallet and when I was about to look for said SSS
ID, I found out that it was no longer where I kept it and was missing;

4. That I diligently searched for my SSS ID and as all efforts to find the
same proved unrewarding, it is now safe to conclude that recovery
of the same is an impossibility;

5. As such, I am executing this Affidavit of Loss to attest to the truth of

the foregoing and to support my application for the issuance of a
new SSS ID in lieu of the one that was lost and for other legal
purposes that this Affidavit could serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 2nd day of

August 2018 at Naguilian, La Union, Philippines.

BERLINDA C. GAPASIN
Affiant
Senior Citizen ID # 8872

SUBSCRIBED AND SWORN to before me this 2nd day of August 2018 at

Naguilian, La Union, Philippines.

ATTY. LOVELLA MAY B. HULIGANGA

Notary Public until December 31, 2018
2nd floor, GACP Arcade Bldg., Ortiz,
Naguilian, La Union
Roll No. 62463; 04.29.13
IBP No. 23888; 01.10.18
PTR No. 2699465; 01.03.18; La Union
MCLE Compliance No. V-0002517; 05.29.14
TIN No. 255-518-493

Doc. No. _______

Page No. ______
Book No. _______
Series of 2018