Republic of the Philippines)

City of____________ ) S.S.

AFFIDAVIT OF LOSS

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

_____________________, after having been sworn in accordance with law, hereby states
and depose and state that:

1. I am the owner owner of Globe prepaid sim card with number _________________;

2. That on_________________, the abovementioned Globe prepaid sim card was

stolen along with the cellular phone;

3. Despite dilligent efforts, I could not find and locate the same, it could no longer be
found and proved to be beyond recovery;

4. That this Affidavit was executed to attest the truth of the foregoing facts and for the
issuance of a replacement sim card with the same number as mentioned above in
my favor and for whatever legal purpose it may serve

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

________________ 2022 at Las Piñas City, Philippines.

__________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ____________ 2022 in

________________ with affiant exhibiting her Philhealth ID with
No._____________________.

Doc No. ______

Page No. _____
Book No. _____
Series of 2022.