Republic of the Philippines )

______________ ) SS.
X-----------------X

AFFIDAVIT OF LOSS
I, (AFFIANT), of legal age, Filipino, (CIVIL STATUS), and resident of
(ADDRESS), after having been duly sworn in accordance with law, do hereby
depose and state:

1. That I am a holder of a GLOBE SIM CARD with (SIM CARD NO);

2. That unfortunately last (DATE), while I was in the downtown

area of Tacloban City, my Cellphone unit with Globe Sim Card
was accidentally lost;

3. That despite diligent efforts to retrieve the same, all my efforts

proved to no avail and considered it now deemed lost so that I
have executed this affidavit to confirm its loss;

4. That I now desire and hereby request the (NETWORK)to issue

me a new Sim Card with the same number in lieu of the lost one;

5. That I attest to the truth and veracity of my afore-mentioned

declarations to the best of my knowledge.

IN WITNESS WHEREOF I have hereunto set my hand this

_________________ at ____________________.

(NAME)
Affiant
ID No__________

SUBSCRIBED AND SWORN to before me this ______________ at

____________________________

Doc. No. _____

Page No. _____
Book No. _____
Series of 202_.