Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of____________)

AFFIDAVIT OF LOSS

I, Joemarie Coloma, Filipino, of legal age and with office address at No. 22 General

Wood St SFDM QC, after being duly sworn in accordance with law, depose and state:

1. That I am a  Delivery Driver of Golden Dragon System International Corporation, a

domestic corporation with office address stated above handling PLDT LANDLINE
PLUS SIM Card with No 666-1985;

2. That in the afternoon of September 22 , 2016, I forgot my Cherry Mobile A7 cellular

phone with the said SIM Card in it inside my deliver van which I have parked along
Gilmore area;

3. That when I returned to my truck, I discovered that my cellular phone was missing
together with my said Mobile SIM Card which was inside the said cellular phone;

4. 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;

5. 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

Joemarie Coloma