REPUBLIC OF THE PHILIPPINES)

CITY OF LAS PIÑAS ) S.S

AFFIDAVIT OF LOSS

I, FERLYN KIARA O. REVILLO, of legal age, Single, Filipino, and Residing at Block
31 Lot 4 Paragon Village, Cabuco City of Trece Martires Cavite, after having been duly
sworn to in accordance with the law, depose and state THAT:

1. I am the same and identical person who executed this Affidavit of loss.;

2. I am a holder of a Samsung A54 With Globe SIM Card 09171747994

Issued by Globe Telecom

3. Sometime on August 28, 2023, at 3:00 PM I was in Alabang Town Center and
I went to the Comfort room for my personal necessities at that time I put my
cell phone on the Top of the Toilet and I immediately out from the bathroom
suddenly I forget my cellphone in Comfort room when I came back I
discovered that it was lost and I reported to security management of ATC
and even in Lost and Found when I track it via Laptop and I log in my
Samsung Account I found my cellphone is already in CAA Las pinas and
nowhere to be found;

4. Despite diligent efforts to retrieve or otherwise recover My Samsung A54

With Globe SIM Card 09171747994 issued by Globe Telecom the same
could no longer be recovered;

5. For purposes of applying for issuance of the Samsung A54 With Globe SIM
Card 09171747994 issued by Globe Telecom I am compelled to execute
this affidavit of loss;

6. Thus, I am executing this affidavit of loss to attest to the truthfulness of the

foregoing, to request for the replacement, and for whatever legal intents and
purposes it may serve;

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereby affix my signature this __ day of _______ 2023

at ___________ Philippines.

FERLYN KIARA O. REVILLO

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ___________2023

at____________, Philippines with affiant exhibiting to me her Philsys 3294-0168-2092-
6154 certify that I personally examined affiant and I am satisfied that she executed this
affidavit freely, intelligently and voluntarily.

Doc. No.: ______

Page No.: ______
Book No.: ______
Series of 2023.