Republic of the Philippines)

City of ______________ ) S.S.

AFFIDAVIT OF LOSS

I, __________________, Filipino, of legal age, and a resident of

____________________________________, after being duly sworn to in accordance with law, hereby
depose and state that:

1. I am regular user of a Globe Mobile Subscriber Identity Module (SIM) Card with No.
___________________;

2. On ________________, when I left the premises of _____________________ after dining in,

I also left my cellular phone where the said SIM card is inserted;

3. A few minutes after noticing that my cellular phone was not with me, I returned to the said
restaurant and inquired to the security guard and waiters-in-charge if they had seen a
cellular phone, but to no avail;

4. I failed to recover my cellular phone and the said SIM card despite diligent search and
earnest efforts to contact and locate said phone; and I consider the same as lost and can no
longer be found;

5. As such, I am executing this Affidavit to attest to the truth of the foregoing and in support of
my application for the replacement of the said SIM card and for whatever legal intents and
purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________at_____________,

Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this _________________________, affiant having

exhibited to me his __________________ issued on ______________ at _________________, as
evidence of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019.