Republic of the Philippines )

Province of Bulacan ) Sc.

City of Malolos )

AFFIDAVIT OF LOSS
I, ___________________, Filipino citizen, of legal age, married to __________________ and a
resident of ___________________, after having sworn to in accordance with law hereby deposes and
states that:

1. That I am a verified holder of a SIM Card with Mobile No. ____________ issued on
______________ by _____________:
2. That sometime on ________________________, while I was on
_______________________, and __________________________:
3. That I have exerted diligent and extra effort to retrieve the aforesaid item but my effort
prove to be futile and to no avail;
4. That I have executed this affidavit the issuance, retrieval and restoration of my SIM card and
to attest to the veracity and truthfulness of the foregoing statement and for whatever legal
intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of ________, 2021
in City Malolos, Bulacan, Philippines

_____________________________

Affiant

SUBSCRIBED AND SWORN, to before me this 26 th day of November, 2021 at City of Malolos,
Bulacan, affiant exhibiting to me her competent proof of identity.

Doc No. ____

Page No.____
Book No.____
Series of 2021.