REPUBLIC 

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

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

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

1. I am a holder/owner of GLOBE SIM CARD with number

_______________________________;

2. Sometime on _________________, said Globe Sim Card was lost

together with my cellular phone;

3. Efforts were exerted to locate and recover said Globe 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 Globe 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 identity.

WITNESS MY HAND AND SEAL

Doc. No. _____;

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