REPUBLIC OF THE PHILIPPINES ) CITY OF MANILA )SS.

X-----------------------------------------X AFFIDAVIT OF LOSS I, (insert name here), Filipino, of legal age, single and a resident of (insert address here), Philippines, after having duly sworn to in accordance with law, hereby depose and say that: 1. 2. I am the holder of a Subscriber Identity Modeule (SIM) Card Number (insert number here) issued by Globe Telecom; I lost said SIM card on (insert date here) and that I exerted all efforts to locate the same but I could not remember exactly where I placed/left it and it is considered lost for all legal purposes; Said SIM Card was not confiscated by any officer of the law by reason of any violation of any law, ordinance, presidential decree or rules and regulation of anything; and neither was it offered as collateral for any loan; I am executing this affidavit to attest to the foregoing facts;

3.

4.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in the City of ___________, Philippines.
(Insert Name of Affiant) Affiant SUBSCRIBED AND SWORN to before me this _______________ in the City of ____________ Philippines, affiant having exhibited to me (his or her) community tax certificate with no. _______________ issued on ______________ at _____________. Doc. No.____; Page No.____; Book No.____; Series of 2013.