Republic of the Philippines)

Cagayan de Oro City) S.S.

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

AFFIDAVIT OF LOSS

I,

____________

Filipino,

of

legal age and a resident

of

_____________________________ , Cagayan de Oro City, Philippines, after

being duly sworn in accordance with law, depose and state:

That I am a regular subscriber / user of a Globe Mobile SIM Card with No.
09__________ ;

That in the afternoon of ___________ , while walking along ________ ,

___________________ , Cagayan De Oro City, I placed my Samsung
cellular phone with the said SIM Card in it inside my bag;

That when I left the premises, I discovered that my cellular phone was
missing together with my said Mobile SIM Card which was inside the said
cellular phone;

That despite diligent search and efforts to locate said cellular phone, I could
not find the same such that I now believe that said is now lost beyond
recovery together with the aforesaid SIM Card;

As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and in support of my request /application for the replacement of
the said SIM Card.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of

September, 2016 at Cagayan de Oro City, Philippines.

__ ___________________
Affiant

ID No:
SUBCRIBED AND SWORN TO before me this SEPTEMBER 16,
2016 in Cagayan de Oro City, Philippines, affiant exhibiting to me his/her
competent evidence of identity by way of a VOTERS IDENTIFICATION CARD
issued at Ditsaan-Ramain, Lanao del Sur.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.