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. 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 SMART SIM CARD:
Name: ____________________________________________
Address: ____________________________________________
Date of Birth: ____________________________________________
Sex: ____________________________________________
Mobile Number: ____________________________________________
Other information: ____________________________________________
2. Sometime on _________________________, said Smart Sim Card was lost
together with my cellular phone;
3. Efforts were exerted to locate and recover said Smart 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 for the issuance of a new
Smart 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__.