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Affidavit of Loss for SSS Form

1) Evelyn Gemina applied for a maternity benefit from the Social Security System in 2013 and was required to complete a Maternity Notification Form. 2) She has since discovered that the Maternity Notification Form is missing and despite searching, she has been unable to find it. 3) She is executing this affidavit to attest that the form is lost and to allow her to reapply for the maternity benefit from SSS.

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leslie ann rase
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75 views2 pages

Affidavit of Loss for SSS Form

1) Evelyn Gemina applied for a maternity benefit from the Social Security System in 2013 and was required to complete a Maternity Notification Form. 2) She has since discovered that the Maternity Notification Form is missing and despite searching, she has been unable to find it. 3) She is executing this affidavit to attest that the form is lost and to allow her to reapply for the maternity benefit from SSS.

Uploaded by

leslie ann rase
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES)

CITY OF ILOILO ) S.S.


x--------------------------------------------------x

AFFIDAVIT OF LOSS

I, EVELYN GEMINA, of legal age, Filipino, married, and a resident


of Brgy. Bulad, Guimbal, Iloilo, Philippines, after having been duly sworn
to in accordance with law hereby voluntarily depose and say that:

1. Last 2013, I applied for a Maternity Benefit before the Social Security
System (SSS) Iloilo Branch;

2. By virtue of such application, I was required to accomplish the


Maternity Notification Form;

3. However, sometime last month, I discovered that the said Maternity


Notification Form is no longer in the place where I usually keep the
same;

4. Despite my diligent search and efforts, I cannot find the said Maternity
Notification Form;

5. Henceforth, I consider it as lost and beyond recovery;

6. I am executing this affidavit to the truthfulness of the foregoing. This


Affidavit attests for the purpose of allowing me to apply for the afore-
mentioned benefit in the SSS.

IN WITNESS WHEREOF, I have hereunto set my hand this


_______________ in the City of Iloilo, Philippines.

EVELYN GEMINA
Affiant
UMID ID No. CRN-0111-0056331-0

The affiant, whose name and personal circumstances are stated


above, personally appeared before me this _______ in the City of Iloilo,
Philippines, presented the foregoing affidavit, signed the same in my
presence and affirmed under oath to the correctness of the contents or
allegations of the same.
The affiant was identified by competent evidence of identity
appearing below his name.

Doc. No. ___;


Page No. ___;
Book No. ___;
Series of 2021.

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