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Republic of the Philippines )

Meycauayan City Bulacan ) S.S


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 _______________.



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.