Free affidavit of loss template
An affidavit of loss format for the Philippines with the Republic of the Philippines S.S. caption, the circumstances of the loss, the purpose and a notarial jurat. Sample affidavit for a lost SSS UMID card included.
What's in this template
Affidavit of loss
Starting point, not legal advice. Print on long bond paper (8.5 x 13 in), sign it only in front of a notary public in the city or province where you swear it, and bring two valid government IDs and the notarial fee. Some offices, such as the SSS, LTO, banks and PSA, have their own required wording or ask for a police or barangay blotter report, so check with the office first. Delete this note before printing.
Republic of the Philippines )
City of Pasig ) S.S.
x--------------------------------x
I, JONATHAN P. MERCADO, of legal age, Filipino, single, and residing at Unit 4B, Rosal Apartments, 18 F. Legaspi Street, Barangay Maybunga, Pasig City 1607, after having been duly sworn in accordance with law, hereby depose and state that:
I am a member of the Social Security System (SSS) with SS Number 34-5582917-6, and I was issued a Unified Multi-Purpose ID (UMID) card with Common Reference Number 0111-5582917-6.
On 14 October 2026, at about 6:30 in the evening, I rode a jeepney from Ortigas Center going to Barangay Maybunga, Pasig City. I kept my wallet, which contained my UMID card, my company ID and about ₱1,200.00 in cash, in the front pocket of my backpack.
When I got off at the corner of Dr. Sixto Antonio Avenue and F. Legaspi Street, I noticed that the front pocket of my backpack was open and my wallet was gone.
I went back along the route and asked the jeepney driver and the nearby stores, but I could not find the wallet. On 15 October 2026 I reported the loss at the Barangay Maybunga hall, recorded in the barangay blotter as Entry No. 2026-1184.
Despite diligent search and efforts, my UMID card could no longer be found or recovered, and I believe it is now lost beyond recovery.
The UMID card has not been pledged, sold or given to any person as security for any obligation.
Should the UMID card be found later, I undertake to surrender it to the SSS and to inform them at once that it has been recovered.
I am executing this affidavit to attest to the truth of the foregoing facts and to support my application with the Social Security System, Pasig-Pioneer Branch, for the replacement of my UMID card, and for whatever legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 28th day of October 2026 in Pasig City, Philippines.
____________________
JONATHAN P. MERCADO
Affiant
SUBSCRIBED AND SWORN to before me this ____ day of __________ 2026 in Pasig City, Philippines, affiant exhibiting to me his Philippine Identification Card No. 2296-0471-5583-1190 and his Passport No. P7745128B issued at DFA Manila on 3 February 2024, as competent evidence of identity.
____________________
Notary Public
Commission No. ________ valid until ________
Roll of Attorneys No. ________
PTR No. ________ / IBP No. ________
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2026.
Find it in: Affidavit of loss sample