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REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.


City/Municipality of _____________)
x-----------------------x

AFFIDAVIT OF LOSS

I, MARIA YVETTE AREVALO, Filipino, of legal age with an address at 55 Visayas


St. Filipinas Village, Brgy. Malanday, Marikina City, Philippines, after being duly sworn in
accordance with law, depose and state:

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


+639178127397;

2. That in the afternoon of January 17 2016, a thief entered into our residence and took
my Apple 6 plus with the said SIM Card inside our house;

3. That I have reported this incident to the police and I am attaching a certified true copy
of a blotter report in this affidavit as Annex;

4. 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;

5. 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
and for whatever purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at


_____________, Philippines.

MARIA YVETTE AREVALO


AFFIANT

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in the (Province/City/Municipality) of _____________,


personally appeared _____________ with Community Tax Certificate No. _____________ issued
on _____________ at _____________, personally known to me (or whom I have identified
through competent evidence of identity) and who represented to me that his/her signature on the
foregoing instrument was voluntarily affixed by him/her for the purposes stated in the instrument
and who declared that he/she has executed the foregoing instrument as his/her free and voluntary
act and deed.
This Instrument consists of only ______ (____) page/s, including this page in which this
acknowledgment is written, duly signed by _____________ and his/her instrumental witnesses on
each and every page hereof.

WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.

NOTARY PUBLIC

Doc. No. ______;


Page No. ______;
Book No.______;
Series of 20____.

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