Republic of the Philippines )

Province of Province of Cagayan ) S.S.

City/Municipality of Tuguegarao )

AFFIDAVIT OF LOSS

I, MARIBEL D. TAMAYAO, Filipino, of legal age and a resident of 62 Atulayan Norte,

Tuguegarao City, Cagayan, Philippines, after being duly sworn in accordance with law, depose
and state:

That I am a regular subscriber / user of a Globe Mobile SIM Card with No.
09165979642;

That in the afternoon of July 30, 2017, my Samsung cellular phone with the said SIM
Card in it was lost while I am buying some medicines in a drugstore;

That despite diligent search and efforts to locate said cellular phone, I could not find the
same such that I now believe that said is now lost beyond recovery together with the
aforesaid SIM Card;

As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and in
support of my request / application for the replacement of the said SIM Card.

IN WITNESS WHEREOF,I have hereunto set my hand this 31st day of July at
Tuguegarao City, Philippines.

MARIBEL D. TAMAYAO
Affiant

SUBSCRIBED AND SWORN to before me, this 31st day of July, 2017 in Tuguegarao
City, with affiant exhibiting his CTC No. _______________ , Issued on
______________________ at _________________________.

NOTARY PUBLIC

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 2017.