You are on page 1of 1

Republic of the Philippines )

Meycauayan City Bulacan ) S.S

AFFIDAVIT

I RAYMUNDO R. BAÑEZ JR., Filipino, of legal age, single and a resident


of of 73 Sampaguita Street, Sta. Lucia Village 1, Veinte Reales, Valenzuela City,
after being duly sworn in accordance with law, depose and state that:

1. I am a regular subscriber/user of the following Subscriber Identity


Module (SIM) Card:

a. Smart SIM Card with No. +63 9294768662


b. Globe SIM Card with No. +63 917907362

2. On 14 January 2018, my mobile phone was stolen and/or lost


somewhere in McArthur highway going to Meycauayan, which included the
above mentioned postpaid SIM Card;

3. Despite diligent effort exerted to recover the same, the said mobile
phone with SIM Cards can no longer be recovered and thus, considered lost
for all legal purposes;

4. The said Sim Card is not confiscated by any person in authority;

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


of the foregoing and to support of my request for the replacement of the said
SIM Card.

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


January 2018 at _______________.

RAYMUNDO R. BAÑEZ JR.


Affiant

SUBSCRIBED AND SWORN to before me this ____ day of January, 2018,


affiant satisfactorily proven to me his identity through his
___________________and, that he is the same person who personally signed
before me the foregoing affidavit and acknowledged that he executed the same.

Doc No. ___;


Page No. __;
Book No. __;
Series of 2018.