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 the “SIM Registration
Act”, I hereby provide the following personal information to fully
establish my ownership of a lost DITO SIM CARD:
Name: ____________________________________________
Address: ____________________________________________
Date of Birth: ____________________________________________
Sex: ____________________________________________
Mobile Number: ____________________________________________
Other information: ____________________________________________
2. Sometime on _________________, said Dito Sim Card was lost together
with my cellular phone;
3. Efforts were exerted to locate and recover said Dito Sim Card, but in
spite of diligent search and effort, it could not be found and the same
is now beyond recovery; and
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
Dito 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__.