REPUBLIC OF THE PHILIPPINES

CITY OF PARAAQUE

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S. S.

AFFIDAVIT OF LOSS
I, JANE DOE, Filipino, of legal age, with residence and postal address at #1234 23 rd
Street San Agustin Village, Moonwalk, Paraaque City, after having been sworn according to
law, hereby depose and say:
1. That I am the holder of a Cellular Number 0910334343 (sim card), Globe network;
2. That the said sim card was inserted to my cellphone;
3. That unfortunately sometime in July 1, 2015, the said cellphone was accidentally lost;
4. That despite of diligent effort to locate the said cellphone, the same could no longer
be found and remain futile in vain;
5. That I intend to keep the said Cellular Number 0910334343 for personal and business
purpose;
6. That I am executing this Affidavit to attest the veracity of the foregoing facts and for
any legal intents and purposes.
IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ of
_______________, 2015 at Paraaque City.
SHERWIN Q. BERO
Affidavit
Valid ID No. _________________
SUBSCRIBED AND SWORN to before me this _____ day of _______________, 2015
at Paraaque City; affiant exhibited to me his Valid IDs below his respective names.

NOTARY PUBLIC

Doc No. ____;

Page No. ___;
Book No. ___;
Series of 2015.