REPUBLIC OF THE PHILIPPINES

CITY OF CABANATUAN )S.S.

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

AFFIDAVIT OF LOSS

I, DORIS MACACULOP RULLAN of legal age, Filipino and a resident of

Brgy. Poblacion Sur, Rizal, Nueva Ecija after having been duly sworn to in
accordance with law hereby depose and say:

1. That I am the owner of a Cellular Phone with Smart Sim No.

0921-577-7735;

2. That the said smart sim card was lost in my possession;

3. That despite diligent search and effort to locate said cellphone

with smart sim card 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. Likewise, I am executing this
Affidavit for the replacement of the said lost item.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of

November 2017, here at Cabanatuan City.

DORIS M. RULLAN
Affiant
SUBSCRIBED AND SWORN to before me this 16th day of November
2017, here at Cabanatuan City.

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