Republic of the Philippines )

City of Dipolog                    ) S.S

x--------------------------------x 

AFFIDAVIT OF LOSS

I, JEFFERSON R. SENO JR., Filipino, of legal age, single/married and a resident of

Purok Bulahan, Turno, Dipolog City, after having duly sworn in accordance with law, do
hereby depose and state THAT:

1. That I am a regular subscriber user of a Smart/Talk N Text Mobile SIM Card

with No.09507889068;

2. That sometime on 9th of May 2020, I forgot my Cherry mobile C29i cellular
phone with the said SIM Card in it inside my packbag;

3. That when I went to my home at around 7 pm., I discovered that my cellular

phone was missing together with my said Mobile SIM Card which was inside the
said cellular phone;
 
4. That despite diligent search and efforts to locate said cellular phone, I could not
find the same such that I now believe that said is now lost beyond recovery
together with the aforesaid SIM Card; ;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and in support of my request / application for the replacement of the
said SIM Card.

  IN WITNESS WHEREOF, I have hereunto affixed my hand this __________ at Dipolog

City, Philippines.
 

JEFFERSON R. SENO JR.

Affiant

SUBSCRIBE AND SWORN to before me this ___________ at Dipolog City, Philippines,

with affiant exhibiting to me his Valid ID No.

Doc. No.___
Page No.___
Book No. III
Series of 2020