Republic of the Philippines)

Province of ____________________) S.S.

City/Municipality of _____________)
x-------------x
AFFIDAVIT OF LOSS
I, LOUIE P. CARANO-O, 38 years old, Filipino, married, and a resident of Brgy. Dalig
2, Antipolo City, Rizal, Philippines, after having been duly sworn in accordance with law, hereby
depose and state:
That on April 7, 2014, when I was riding a jeepney on my way home to Antipolo, I noticed
that my wallet was lost containing my SSS ID, Philhealth and Pag-ibig Cards;
That despite diligent search and efforts to locate the said IDs, I could not find the same such
that I now believe that it is now lost beyond recovery;
As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support the application for the issuance of new one in lieu of the one that was lost.
IN WITNESS THEREOF, I have hereunto set my hand this April 14, 2014 at Port Area, Manila,
Philippines.

LOUIE P. CARANO-O
Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by _____________________

who exhibited to me his
_____________ issued by _______________________ on
_________________.

Notary Public

Doc. No.__________
Page No. _________
Book No. _________
Series of __________