REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S

AFFIDAVIT OF LOSS

I, ____________, of legal age, Filipino citizen, with address at

______________________, having duly sworn in accordance with law, hereby
depose and state that:

1. I am a regular subscriber/user of a Touch Mobile SIM card with number

____________;

2. On 28 August 2019, while travelling in a bus, I discovered that my Samsung

cellphone with the said SIM card was stolen by one of the passengers who
already alighted;

3. Despite diligent efforts to locate said cellphone together with the SIM card,
they are irretrievably lost and can no longer be found;

4. I execute this affidavit to attest to the truth of the foregoing and to request
for a replacement of said mobile SIM card.

IN WITNESS HEREOF, I have hereunto set my hand on this 29th day of August
2019 at Quezon City.

_____________________________
______________

SUBSCRIBED AND SWORN TO before me this 29th day of August 2019 at

Quezon City, Philippines, with affiant appearing before me and exhibiting to me her
____________________ as competent evidence of her identity.

Doc. No.__;
Page No. __;
Book No. __;
Series of 2019.