REPUBLIC 

OF THE PHILIPPINES)
CITY OF PARAÑAQUE ) S.S.
x-------------------------------------------x
 
AFFIDAVIT OF LOSS 

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

________________________________________, after having been duly sworn to in
accordance with law, depose and state THAT:

1. Pursuant to the Implementing Rules and Regulations (IRR) of

Republic Act No. 11934 otherwise known as “SIM Registration Act”, I
hereby provide the following personal information to fully establish
my ownership of a lost TM SIM CARD:
Name: ____________________________________________
Address: ____________________________________________
Date of Birth: ____________________________________________
Sex: ____________________________________________
Mobile Number: ____________________________________________
Other information: ____________________________________________
2. Sometime on _______________________, said TM Sim Card was lost
together with my cellular phone;
3. Efforts were exerted to locate and recover said TM Sim Card, but in
spite of diligent search and effort, it could not be found and the same
is now beyond recovery;
4. I am executing this Affidavit of Loss to attest to the truth of the
foregoing and to support my application to for the issuance of a new
TM Sim Card with number _________________________, in lieu of the
one that was lost.

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

___________________ in Parañaque City, Metro Manila, Philippines.

_________________________
AFFIANT

SUBSCRIBED AND SWORN to before me, this day of _______________ in

Parañaque City, by the affiant who has exhibited to me his/her ____________
with No. ____________________ as competent proof of his/her identity.

WITNESS MY HAND AND SEAL

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 202__.