REPUBLIC OF THE PHILIPPINES)

MANDALUYONG CITY………….) S.S

AFFIDAVIT OF LOSS

I, _______________, of legal age, Filipino, single, and with residence at

______________________________, do hereby depose and state that:

1. I previously have my ________________in my custody;

2. On_____________somewhere in _________________, I noticed

that the said ______________ was already missing from my pocket;

3. Installed in my ____________ is my ________________ SIM Card

with number __________________;

4. Despite diligent efforts exerted, I could no longer locate, find or

recover the said ________________, and to the best of my
knowledge, the same has been stolen and is truly lost;

5. The afore-mentioned _____________/_____________________

SIM Card has not been confiscated by any officer of the law or the
issuing office or agency due to the violation of any law, statute, order,
rule or regulation; and

6. I am executing this Affidavit to attest to the truth of the foregoing

statements and to request the issuance of a new SIM Card using the
same number ___________________ lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have unto set my hand this 27th day of July 2019
in Mandaluyong City.

____________________________
Affiant
SUBSCRIBED AND SWORN TO before me, this ________ day of
__________ 2019, affiant exhibiting to me his I.D. No. ______________.

Doc No.____:
Page No.____;
Book No.____:
Series of 2019.