Republic of the Philippines)

City of Quezon                        ) S.S.

AFFIDAVIT OF LOSS

I, Juan Dela Cruz, Filipino, of legal age, single, and a resident of #30 Dimahanap St. Brgy.
Naglaho, Quezon City, after having been duly sworn to, in accordance with law, do hereby
depose and state that:

1. I was in possession of a cellular phone with Globe SIM card from Globe with cellphone
number 09192598125;
2. Sometime in September 7, 2021 I am on my way home from work and while driving my
motorcycle I put my cellular phone in my pocket.
3. Unfortunately, I forgot to check it from time to time. Upon realizing that I did not have it
with me I immediately returned to the road where I drove. However, I did not find it
along the road where I passed by;
4. I searched everywhere and asked around as to who might have found it or noticed it.
However, I did not find it;
5. I have exerted efforts to locate the phone in all possible places but to no avail. In the
event that I find them I will inform the proper parties about it;
6. I am executing this document to attest to the truth of the foregoing statements and for
the purpose of issuance of a new Sim Card with the same number from Globe.

_______________________

Affiant
ID: ____________________

SUBSCRIBED AND SWORN to, this ______________________, the affiant personally appeared and
presented to me his/her competent evidence of identity shown above.

Doc. No.: __________;

Page No.: __________;
Book No.: __________;
Series of 20___.