REPUBLIC OF THE PHILIPPINES)

Province of Negros Oriental) S.S.

Municipality of Sibulan) 

AFFIDAVIT OF LOSS (SMART SIM CARD)

I, DONNABEL S. ADVINCULA, Filipino, of legal age, with postal address at Magatas,

Sibulan, Negros Oriental, Philippines after having been sworn in accordance with law hereby
depose and state:

1. That I was issued a Smart Sim Card with No. 09685037417 by the
Department of Education (DepEd);
2. That sometime on May 2022, I could no longer find the said Smart Sim Card
with No. 09685037417. Perhaps, it was misplaced somewhere;
3. That despite diligent search and efforts to locate said sim card, I could not find
it;

4. That I am executing this affidavit to attest to the truth of the foregoing facts
and to request for a replacement of my Smart Sim Card.
IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at
Sibulan, Negros Oriental, Philippines.
                              
DONNABEL S. ADVINCULA
Affiant

SUBSCRIBED AND SWORN TO before me this _____________ at Sibulan, Negros

Oriental, affiant exhibited to me her PRC ID No. 0486500 valid until 08/03/2022, bearing the
affiant’s photograph and signature, thru which her identity was confirmed.

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2022.