REPUBLIC OF THE PHILIPPINES

CITY OF CABANATUAN )S.S.

X---------------------------X

AFFIDAVIT OF LOSS

I, DANILO R. PADIERNOS of legal age, Filipino resident of Brgy. Aduas

Sur, Cabanatuan City, Nueva Ecija after having been duly sworn to in
accordancewith law hereby depose and say:

1. That I am a holder of Smart Sim with No. 0928-342-1721;

2. That sometimes on June 27, 2017 said smart sim with my

cellular phone was lost;

3. That despite diligent effort to locate said missing cellular phone

with smart sim same could no longer be found;

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

foregoing and for the purpose of informing the concerned
authorities about this fact and to replace the said smartsim.
Likewise, I am executing this Affidavit for any legal intents and
purposes it may serve.

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

___________ 2017 here at Cabanatuan City.

DANILO R. PADIERNOS
Affiant

SUBSCRIBED AND SWORN to before me this __th day of _________

2017 here at Cabanatuan City.

Doc. No.______
Page No.______
Book No._____
Series of 2017.