REPUBLIC OF THE PHILIPPINES )

QUEZON CITY
)S. S.
x-----------------------------------------x
AFFIDAVIT OF LOSS
I, _________________________, single, of legal age, Filipino, with office address at
___________________________________, do hereby depose and say that:
1. I am the owner of Samsung J7 with Globe Prepaid Sim Number ___________;
2. That on the night of September 23, 2016 on or about 9:00pm, I took a bus at Cubao
Edsa,Q.C. to get to our hometown in Marilao, Bulacan;
3. When I got off from the bus, I noticed that my cellphone Samsung J7 with the
abovementioned Globe Prepaid Sim was missing;
4. That I tried to catch bus which I rode in order to look for my missing cellphone but the
bus was too far already;
5. That I still tried to catch a glimpse of the buss plate number but still it was futile;
6. After exerting efforts, my Samsung J7 with the Globe Prepaid Sim Card in it is now
missing or lost and I could no longer locate the same;
7. That I am executing this affidavit to attest to the truth of all the foregoing and in order
for me to secure another Globe Prepaid Sim Card with the same number from Globe Telecom.
IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of September, 2016
at Quezon City.

_____________________________
Affiant
SUBSCRIBED AND SWORN TO before me this September 26, 2016 in Quezon City,
affiant exhibited to me his government ID no. ________________________ issued at
______________________ on ____________________.
Doc. No.
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Page No.
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Book No.
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Series of 2016