Republic of the Philippines )

City of _________________) S.S

AFFIDAVIT OF LOSS
I, Chavy L. Monton, of legal age, with postal address at No. 3 Camanacsan
San Jose Nueva Ecija after having been duly sworn in accordance with law, depose
and state THAT:
1. I am currently a Distributor Specialist at Imported House Inc.;
1. That at around 7:00 in the evening of 6 June 2006, I took a jeepney ride from
Monumento, Caloocan to Valenzuela City;
2. That upon boarding the jeepney in Monumento, Caloocan going to
Valenzuela, a pickpocketer had stolen my wallet.
3. That I am not aware when my wallet was gone after I had embark from the
same jeepney.
4. That SSS I.D., Drivers License and other government IDs were in my
wallet when this incident happened;
5. That I am executing this Affidavit for the re-issuance of a new SSS. I.D., and
for whatever legal purpose this may serve.
Affiant further sayeth naught.

Chavy L. Monton
Affiant
SUBSCRIBED AND SWORN to before me this _____ day of June, 2014 in
the City of ______________________, herein Affiant exhibiting to me his Drivers
License No. N04-94-322606 which shall expire at October 29, 2015.
NOTARY PUBLIC
Doc. No. ____;
Page No.____;
Book No.____;
Series of 2014.