Republic of the Philippines)

_____________________) S.S.

AFFIDAVIT OF LOSS

I, (Name), of legal age, single,

(address), under oath, depose and state:

Filipino

citizen,

with

postal

address

at

(1) I am a Student of Technological Institute of the Philippines with office address at the 1338
Arlegui St. Quiapo, Manila
(2) I am a regular subscriber / user of a TOUCH MOBILE SIM Card with No.
(3) Sometime in (Date) I lost the above TOUCH MOBILE SIM under the following
circumstances:
In my everyday way to and from the School, I used to commute in Public Utility Vehicles such as
jeepney, bus and/or Light Rail Transit (LRT), carrying my bagpack containing my mobile phone
with my sim cards. I was just surprised to have known that my mobile phone, was already
missing as it might have accidentally fell-off from the side-pocket of my bag then while
commuting on my way to home.
(4) Despite diligent efforts exerted, I could no longer locate, find or recover the said SIM Card,
and to the best of my knowledge, the same is truly lost.
(5) I am executing this Affidavit to attest to the truth of the foregoing statements and to request
the issuance of a new TOUCH MOBILE SIM in lieu of the one which was lost.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________________

at
_____________________________________.

Name
Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant exhibited to me

his/her Competent Evidence of Identity by way of __________________ issued at
______________ on __________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.