Republic of the Philippines)

City of Baguio ) S.S.

AFFIDAVIT OF LOSS

I, Coups Data, of legal age, married to Habeas Data, Filipino Citizen and with
residence at No. 1 Writ Kalikasan, Baguio City, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. I am in possession of a sim card with number 091801202312;

2. On January 18, 2023, while I was walking along the Baguio City
market, I noticed that my sim card was missing from my pocket.

3. Despite diligent efforts to locate it, the same can no longer be found.

4. I am executing this affidavit to attest to the truth of the foregoing and

for all legal intents and purposes, including the replacement of the sim with the same
number;

IN WITNESS WHEREOF, I have hereunto set my hand this 28th day of

January 2023 at Baguio City, Philippines.

COUPS DATA
Affiant
TIN: 123-456-789-000

SUBSCRIBED AND SWORN to before me this ____ day of

____________________ at Baguio City, Philippines. Affiant presenting to me his
proper identification, the specific of which is herein indicated below his name and
signature.

Doc. No.______:
Page No.______:
Book No.______:
Series of 2023.