REPUBLIC OF THE PHILIPPINES )
CITY OF MANILA )SS.
 X-----------------------------------------X
 

AFFIDAVIT OF LOSS

I, (insert name here), Filipino, of legal age, single and a resident of (insert address
here), Philippines, after having duly sworn to in accordance with law, hereby depose and
say that:
 
1. I am the holder of a Subscriber Identity Modeule (SIM) Card Number (insert
number here) issued by Globe Telecom;
 
2. I lost said SIM card on (insert date here) and that I exerted all efforts to
locate the same but I could not remember exactly where I placed/left it and it is
considered lost for all legal purposes;
 
3. Said SIM Card was not confiscated by any officer of the law by reason of any
violation of any law, ordinance, presidential decree or rules and regulation of
anything; and neither was it offered as collateral for any loan;
 
4. I am executing this affidavit to attest to the foregoing facts;
 
IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in the City of
___________, Philippines.
 

(Insert Name of Affiant)

  Affiant
 

SUBSCRIBED AND SWORN to before me this _______________ in the City of ____________

Philippines, affiant having exhibited to me his/her ______________________
with no. _______________ issued on ______________ at _____________.
 
Doc. No.____;
Page No.____;
Book No.____;
Series of ______.