REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S.

AFFIDAVIT OF LOSS

I, (YOUR NAME), Filipino, of legal age, with address at [address], after

having been sworn in accordance with law, hereby state that -

1. I am the owner of the Globe SIM card with number _____ which
was bought some time between 2015 and 2016.

2. I used the said SIM card number to register in most social media
accounts that I have.

3. Despite having exerted diligent efforts in trying to recover said SIM

card, I can no longer find the same.

4. The said SIM card was misplaced/lost while the phone it was
inserted in was lent to my aunt and now it appears to be beyond recovery.

5. I am executing this affidavit in order to attest to the truth of the

foregoing, and for any and all other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this [date]

at Quezon City.

Qkirt Ogaya (real name mo)

Affiant

SUBSCRIBED AND SWORN to before me this 29th of January 2018,

affiant exhibiting to me his community tax certificate no. _______ issued at
Quezon City on _____________.

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