REPUBLIC OF THE PHILIPPINES )

PROVINCE OF NUEVA ECIJA ) S.S.

CITY OF GAPAN )
X - - - - - - - - - - - - -x

AFFIDAVIT OF LOSS

I, _______________________, of legal age, Filipino, and a resident of San

Roque, San Isidro, Nueva Ecija, after having been duly sworn to in
accordance with law hereby depose and say:

1. That I am the holder/owner of a Globe Landline Phone with

No. ____________________;

2. That I put said phone inside my bag but sometime on July 25, 2019
when I searched for it, said Globe Landline Phone was already
missing;

3. That diligent effort has been made to find the said Globe Landline
Phone but to no avail;

4. That I am executing this affidavit to attest the truthfulness of the

foregoing facts and to request the proper authority concerned to issue
me a new phone.

IN WITNESS WHEREOF, I have hereunto set my signature this 4 th day

of September, 2019 here at Gapan City.

XXXXXXXXX
Affiant
ID No. XXXXXXX
Issued By: XXXXXX

SUBSCRIBED AND SWORN TO BEFORE ME, this 4th day of September,

2019 here at Gapan City. Affiant presented to me her identification card
indicated below her signature.

XXXXXXXXXXXXXXXXXXXXXXX
Notary Public
Until DYYYYYYYYYYYYYYY
PTR No. __________________
Doc. No. 0; At__________________________

Page No. 0;
Book No. 0;
Series of 0.