REPUBLIC OF THE PHILIPPINES)

________________________ ) S.S.

AFFIDAVIT OF LOSS

I, ____________________, of legal age, single, Filipino and resident of ___________________________, after

having been duly sworn to in accordance with the law hereby depose and say;

1. That I am the owner of two (2) Globe SIM card with no. ________________ (Prepaid) and no.
_______________ (Postpaid);

2. That the SIM card no. _________________ was lost/misplaced;

3. That on _______________ during our trip to _____________________________________, my

cellphone ______________________ was damaged because it was accidentally dropped in the
water while swimming;

4. That when I tried to have the cellphone repaired, I took out the SIM card and placed it on my coin
purse;

5. That despite diligent search and efforts when I bought a new cell phone last ________________, I
could not find it on the said purse such that I honestly believe that it is lost beyond recovery;

6. That the said SIM card no_____________________ is linked to my account with

_____________________;

7. That to be able to access my _______________ account, a text message that contains a link to reset
the password will be sent to the linked SIM card no. _________________;

8. That I am executing this affidavit in good faith and without any intention to defraud or deceive;

9. That I am executing this affidavit 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 set my hand this ____________________ in the City of
____________________, Philippines.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this ____________________ in the City of ____________________
Philippines, affiant having exhibited to me her ____________________ issued on ____________________ at
_____________________.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of _______.