Affidavit of Loss

REPUB LIC OF THE PHILIPPINES)

Province__________________ ) SS.

I, ______________________, of legal age and with address at _________, under

oath, depose and states:

1. THAT on the afternoon of September 5, 2020 at _____________ while I was

driving on my way home aboard my electric bike/vehicle I have accidentally lost my
mobile phone, it might have slipped out of my pocket while traversing an unpaved road
towards _______________, it was after a couple of hours before I realized that my
mobile phone was missing;

2. The mobile phone that was lost is a ______________ containing important

notes and messages, including my mobile banking account and E-wallet;

3. THAT even with utmost efforts and diligence to locate the said mobile device
has proven to be impossible as there might have been someone who picked it up and
took interest in it, hence I have considered that the said mobile device is already lost and
incapable of being found;

4. THAT I am voluntarily executing this Affidavit to attest to the truth of the

aforementioned facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ___th day of

____________, 2022 at ____________________________.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this th day of _____________, 2022 at

__________________, Affiant exhibiting to me his valid Govt. Issued identification
Card, with card number ________________ issued at _________________ on
___________________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of 2005.