Affidavit of Loss

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Republic of the Philippines )

Province of Bukidnon ) S.S.

AFFIDAVIT OF LOSS

I, _______________, of legal age, Filipino, single and a


resident of _________________________, after having been sworn to
in accordance with law, hereby depose and say:

1. That I am a plan holder of __________________through a


sim subscription bearing a number ____________;

2. That sometime on __________ my phone was misplaced and


could no longer be found;

3. Despite diligent effort on my part and the other members of


my family, I could no longer recover and locate the said phone and to
the best of my knowledge, the same is truly lost;

4. In view thereof, I now desire and hereby request


_______________ to request a new sim with the same number in lieu
of the lost one;

5. That I am executing this Affidavit to attest to the fact of the


loss of the said plan-subscribed sim and for whatever legal purpose
this may serve;

IN WITNESS WHEREOF, I hereunto affix my signature this


__________ at _________________________.

___________________________
ID No.: ____________________
Issued by: __________________

SUBSCRIBED AND SWORN to before me at the place and date


above-stated by Affiant who exhibited to me her _____ ID above-
described.

Doc # _____;
Page #_____;
Book # ____;
Series of ____.

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