Republic of the Philippines)

City of Olongapo
) S.S.
x-----------------------------------------x

AFFIDAVIT OF LOSS
I, CHARMAINE D. DELA CRUZ, Filipino, of legal age and a resident of No. 12
Labrador Street, Mabayuan, Olongapo City, Philippines, after being duly sworn in
accordance with law, depose and state:
That I am a regular user of a SMART mobile SIM card with No. 0920 424
0308;
That at around 6:00PM of October 6, 2015, I was on the 3 rd floor of SM
Olongapo at Firefly Mobile Store to purchase a new phone;
That the saleslady at the said stall asked me to bring out my SIM card so she
could check if it will work on the new phone;
That as I pulled out the small SIM card, I accidentally did so with force
causing the SIM
card to flip out of my hand;
That there were a lot of people in the stall during that time, and despite my
diligent
search and effort to look for the SIM card in the premises, it was
nowhere to be found,
such that I now believe that it is now lost beyond
recovery;
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
this____________at____________, Philippines.

hereunto

___________________________________
Charmaine D. Dela Cruz
Affiant

set

my

hand

SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of
____________ 20__ at Olongapo City, affiant exhibited to me his Passport No.
EC3516403 issued on February 24, 2015 at DFA Manila.

Notary Public
Doc No. _____
Page No. _____
Book No. _____
Series of 2015.