REPUBLIC OF THE PHILIPPINES)

CALOOCAN CITY ) S.S.

AFFIDAVIT OF LOSS

I, , Filipino, of legal age, and with residence address at, after being duly
sworn to in accordance with law, hereby depose and state:

1. That I am the owner of;

2. That on March 25, 2022 at around 3:30 in the morning while I was
on my way to my house, I dropped the said Cellular phone Unit along Saranay
Road, Bagumbong, Caloocan;

3. That despite diligent search and efforts to locate my Cellular phone

Unit together with the Sim Card, I cannot find the said Cellular phone Unit
together with the Sim Card such that I now have reasons that the same is
lost/cannot be recovered;

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

the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of

______________, 2022, in Caloocan City.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and

in Caloocan City, this __ day of ____________, 2021, affiant personally came and
appeared with as his competent proof of identity, bearing his photograph and
signature, and known to me as the same person who personally signed the
foregoing instrument before me and avowed under penalty of law to the whole
truth of the contents of the said instrument.

Doc. No. __;

Page No. __;
Book No. __;
Series of 2022.