Affidavit of Loss Cell phone SIM Card

Republic of the Philippines)

Province of_________________) S.S.
City/Municipality of____________)
x - - - - - - - - - - - - x

AFFIDAVIT OF LOSS

I,____________, Filipino, of legal age and a resident of

____________, Philippines, after being duly sworn in accordance
with law, depose and state:

That I am a regular subscriber / user of a (Smart / Globe /

Sun)Mobile SIM Card with No._____________;

That in the afternoon of _____________, I forgot my (O2 / Sony-

Ericsson / Motorola / Samsung) cellular phone with the said SIM
Card in it inside my car which I have parked along ____________;

That when I returned to my car at around________, I discovered

that my cellular phone was missing together with my said Mobile
SIM Card which was inside the said cellular phone;

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____________at____________, Philippines.

Affiant

JURAT)