REPUBLIC OF THE PHILIPPINES

CITY OF CABANATUAN )S.S.

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

AFFIDAVIT OF LOSS

I, BONIFACIO S. DEL ROSARIO, of legal age, Filipino and a resident of

Brgy. Dona Lucia, Quezon, Nueva Ecija after having been duly sworn to in
accordance with law hereby depose and say:

1. That I am an owner of a Cellular Phone with Globe Sim No.

09175313815;

2. That yesterday August 29, 2017 around 4:00 P.M I was driving
my motorcycle going in my farm in Quezon, Nueva Ecija,
when I got home I discovered that said Cellular phone with my
Globe sim card was lost, believed that it fell somewhere while I
was driving;

3. That despite diligent effort to locate said cellphone with globe

sim card 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 30 thday of

August 2017, here at Cabanatuan City.

BONIFACIO S. DEL ROSARIO

Affiant
SUBSCRIBED AND SWORN to before me this 30 th day of August 2017,
here at Cabanatuan City.

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