REPUBLIC OF THE PHILIPPINES)

__________________________) S.S.
PROVINCE/CITY OF ________________________)
MUNICIPALITY/DISTRICT OF __________________)

AFFIDAVIT OF LOSS

I, Neriza Arabejo Rodriguez, of legal age, Filipino, L5 B10 PH3 Avida Settings
Nuvali, Canlubang, Calamba, Laguna, after being duly sworn in accordance with law,
depose and state the following:

That I am the lawful owner of a Samsung S21 Ultra smartphone, with IMEI 1:
354505626451132; IMEI 2: 359131206451130;

That on August 29, 2023 at around 2:00 PM, I lost the said smartphone together
with the SIM card installed in it somewhere in Imus, Cavite;

That the SIM card was issued by Globe Telecom and is associated with the
following number: 0917 328 4045;

Despite diligent efforts to locate the device, including retracing my steps,

contacting establishments I visited, and reporting the incident to the local authorities, I
have been unable to recover my smartphone and SIM card;

That I hereby declare that there are no pending insurance claims or disputes
related to the loss of the aforementioned smartphone and SIM card;

I affirm under the penalties of perjury that the foregoing facts and statements are
true and correct to the best of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hand this 7th day of

September, 2023, in Camp BGen Rafael T. Crame, Quezon City.

_____________________________
NERIZA ARABEJO RODRIGUEZ
Affiant

SUBSCRIBED AND SWORN to before me this ________ of September, 2023, in

___________, affiant exhibiting to me his/her valid identification card as follows:

Type of ID: LTO Driver’s License

ID Number: F09-09-000794

______________________________
Notary Public
Doc. No. ________
Page No. ________
Book No.________