REPUBLIC OF THE PHILIPPINES )

City of Manila

) S.S.

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

AFFIDAVIT OF LOSS

I, _______________, of legal age, Filipino, single, and a resident of

________________________________, Philippines after having been duly sworn in accordance
with law, hereby depose and say that:
1. I am a regular user of a Globe Mobile Subscriber Identity Module (SIM) Card with
No.______________ since 2007;
2. On _______________, at about noontime, when I left the premises of
________________ after dining in, I also left my cellular phone where the said SIM Card is
inserted;
3. A few minutes after noticing that my cellular phone is not with me, I returned to the
said restaurant and inquired to the security guard and waiters-in-charge if they have seen a
cellular phone in the spot where I was sitted;
4. I failed to recover my cellular phone and the said SIM Card despite diligent search and
earnest efforts to contact and locate said phone, and I consider the same as lost and can no longer
be found;
5. I am executing this Affidavit to attest to the truth of the foregoing facts and in support
of my application for the replacement of the said SIM Card and for whatever legal intents and
purposes it may serve.
Affiant states nothing further.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ day of _____
__________ in Manila City, Philippines.

_____________________
Affiant
ID Details

SUBSCRIBED AND SWORN TO before me this ______ day of ________ 201_ in Manila City,
Philippines, affiant exhibited her _____________ Identification Card as herein above indicated.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2013.