REPUBLIC OF THE ____________)

__________________ CITY             ) SS.

AFFIDAVIT OF LOSS

I, ____________________________, of legal age, and with address at

___________________________, under oath state:

1.THAT I am a registered owner of SMART Retailer Sim bearing No.

_________________;

2.THAT in the afternoon of Saturday, _______________ 20__, my Nokia 3310

containing said SIM was stolen from our store by an unidentified culprit while I was
busy conducting an inventory of the goods therein;

3.THAT I exerted due diligence and persistent efforts in locating my aforesaid cellphone
and its SIM card but to no avail and I consider the same as lost and can no longer be
found;

4.THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to
use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ___________ at Makati

City.
______________________

Affiant

SUBSCRIBED AND SWORN to before me this ______________ at Makati City,

Affiant exhibiting to me his/her Community Tax Certificate No. ________________
issued on ________________ at ______________.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of: ______