Republic of the Philippines )

City of Baguio ) S.S.

x--------------------------------------x

AFFIDAVIT OF LOSS

I, PAULINE ROSE ANNE FLORES, Filipino, of legal age and a resident of B3L2D
Anthorium St lexberville Subdivision, Balacbac, Baguio Philippines, after being duly sworn
in accordance with law, depose and state:

1. That I am a regular user of a Smart Mobile Sim Card with No. 0929 485 4723;

2. That on __________ , I forgot my Vivo V15 cellular phone with the said SIM Card in
it in a taxi I was riding;

3. That despite diligent search and efforts to locate said cellular phone, I could not find
the same such that I now believe that said is now lost beyond recovery together with
the aforesaid SIM Card;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and in
support of my request / application for the replacement of the said SIM Card.

IN WITNESS WHEREOF I have hereunto set my hand this ____ day of

_____ 2022 at____________, Philippines.

_______________________________________
PAULINE ROSE ANNE FLORES
Affiaint
Passport No.: P5085802B

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me her competent evidence of identity by
way of a Philippine Passport issued at______________ on___________________