Republic of the Philippines)

City of ) s.s.

AFFIDAVIT

I, X of legal age, married, Filipino citizen and resident of A, after having

been sworn in accordance with law, hereby depose and say:

That I am a member of the Social Security System since 1980;

That as member, I was issued an SSS number. But when I inquired from
the SSS database recently, four numbers appeared under the name X.;

That I have no knowledge how these four numbers came to be entered in

my name. But I know that the number used by me in my past transactions is
00000 because this is the number appearing on my SSS identification card;

That since there is another number that can be credited to my name for
having the same entry on date of birth and sex, I hereby request that the said
number which is 1111111 be cancelled.

FURTHER, Affiant sayeth none.

IN WITNESS WHEREOF, I hereunto set my hand this 10 th day of October

2012 at _________ City, Philippines.

X
Affiant

SUBSCRIBED AND SWORN to before me this 10th day of October

2012 at _________________, Affiant exhibiting to me his SSS I.D. No. 0000000.