Republic of the Philippines)

Province of Agusan del Sur ) S.S.

AFFIDAVIT OF LOSS
I, LEZIEL BARRIGA BACSAN , of legal age, married, with residence and postal address
at Purok 6, San Vicente, Prosperidad, Agusan del Sur, being sworn in accordance with law,
depose and say that:

1) I am a subscriber of GLOBE TELECOM and availed their TIPID LOAD 500 Plan with a
monthly payment of Five Hundred Pesos;

2) On such subscription, I was issued a free cellular phone (cellphone) and a sim card
with sim # 09369601081 ;

3) I have been using and carrying such cellphone wherever I go;

4) Last week, that I could not find my cellphone in our house and in my place of
work;

5) Diligent efforts have already been exerted to retrieve my cellphone, but all turned
out futile, as the same might had accidentally fell or could have been snatched from my
pocket as I walk around in the market and boarded a tricycle on my way home;

7) This affidavit is being executed to attest to the veracity of the foregoing facts, and
to request Globe Telecom-San Francisco to issue a new Sim card with the same
09369601081 number, in lieu of the lost one, and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

March 2, 2019

LEZIEL BARRIGA BACSAN

Affiant

SUBSCRIBED AND SWORN to before me this 2nd day of March 2019 at Prosperidad,
Agusan del Sur, affiant exhibiting to me her Department of Education ID bearing #
0600110.

DOC. NO. 64;

PAGE NO. 13;
BOOK NO. V;
SERIES OF 2019.