REPUBLIC OF THE PHILIPPINES)

CITY OF _____)

AFFIDAVIT OF LOSS

I, ___________, of legal age, Filipino citizen and a resident of

Tacloban City, after being duly sworn to in accordance with law, hereby
depose and state:

1. That I am a subscriber of ____ (Network) with the sim card

number ____ (blank);

2. That on Month day, year I lost my ___Phone which contained

the sim card number mentioned above;

3. That despite diligent search and efforts to locate the said

phone, I could not find the same, such that I now believe
that said is now lost beyond recovery;

4. That 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 and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

N day of month, year at ___ City, Philippines.
th

NAME__________________________
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public for and

in the Province of Leyte, this Nth day of Month, Year at Tacloban City.

Doc. No.____;
Page No.____;
Book No. __;
Series of 2021.