Republic of the Philippines )

City of Cebu ) S.S.

AFFIDAVIT OF LOSS

I, XXX, of legal age, Filipino, married, and a resident of B. Rodriguez

Extension, T.B. Pavillion, Cebu City, after having been sworn to in accordance
with law, hereby deposes and states that:

1. I am the owner and in possession of xxx cellphone with the following

details, to wit:

 Model: xxx
 International Mobil Equipment Identity (IMEI) number: xxx
 Subscriber Identity Module (SIM) card number: xxx

2. Sometime on xxx, I went to Western Union – Robinsons Fuente and

made a transaction therein where I inadvertently left my phone;

3. When I noticed that the phone was no longer in my possession, I

immediately returned to the place and inquired as to the whereabouts of my
phone;

4. Upon inquiry, I was informed by the person with whom I transacted with
and by the guard of the said establishment that another man took the phone;

5. Despite of diligent effort to look for the said phone, the same proved
futile and is now beyond recovery and therefore, considered lost for all intents
and purposes;

6. The said incident is reported with the proper authorities and recorded in
the Police Blotter of xxx City Police Office, a copy of which is attached and
forms an integral part of this affidavit;

7. I am executing this affidavit for the purpose of affirming the veracity of

the foregoing statement, for the issuance of a new prepaid SIM card with
number xxx, to disable/lock/block my phone with the details provided above
and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I hereunto set my hand on this __ day of ____, in

the City of Cebu.

xxx
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of _____, in Cebu City,
Philippines, affiant exhibiting to me his __________.

Doc. No. ____;

Page No. ___;
Book No. ____;
Series of 2019.